National seasonal influenza vaccination...

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National seasonal influenza vaccination surveyfor 2012-13 influenza season in EU/EEA

(provisional data)

VENICE III ConsortiumNovember 2013- June 2014

WP2

Developed byJolita Mereckiene

Suzanne CotterDarina O’Flanagan

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ContentsAbbreviations .............................................................................................................................4Acknowledgments......................................................................................................................4ISO 3166-1 Country Codes .........................................................................................................5VENICE National Gatekeepers and Contact Points ....................................................................6Summary ....................................................................................................................................7Background ................................................................................................................................8Objectives...................................................................................................................................9

Aim of the study.....................................................................................................................9Specific objectives..................................................................................................................9

Methodology..............................................................................................................................9Study Design...........................................................................................................................9Data collection .....................................................................................................................10Data handling .......................................................................................................................10Data processing....................................................................................................................10Pilot study ............................................................................................................................10Study time............................................................................................................................10Data analysis ........................................................................................................................10Expected deliverables ..........................................................................................................11

Results......................................................................................................................................11Response rate ......................................................................................................................11

Section I: GROUPS RECOMMENDED SEASONAL INFLUENZA VACCINATION (2012-13influenza season) BY NATIONAL/REGIONAL AUTHORITY ........................................................11

Influenza immunisation policy.............................................................................................11Documents used elaborating/updating policy ................................................................12

Recommendation for entire population..............................................................................14Age groups recommended influenza vaccine......................................................................14

Payment scheme and funding mechanism for age groups .............................................15Clinical risk groups ...............................................................................................................17

Payment scheme and funding mechanism for clinical risk groups .................................20Pregnancy related vaccination.............................................................................................21

Payment scheme and funding mechanism for pregnancy related vaccination ..............23Health care workers.............................................................................................................25

Payment scheme and funding mechanism for HCWs .....................................................26Other occupational groups ..................................................................................................27

Payment scheme and funding mechanism for other occupational groups ....................29Population groups in closed communities...........................................................................31

Payment scheme and funding mechanism for population groups in closed communities..........................................................................................................................................31

Household contacts or care takers ......................................................................................33Payment scheme and funding mechanism for household contacts or care takers ........34

Recommendation for travellers...........................................................................................36Section II: VACCINATION COVERAGE DATA (SEASON 2012-13) ..............................................37Section III: METHODS TO MONITOR VACCINATION COVERAGE, SAFETY AND EFFECTIVENESS..................................................................................................................................................42

Numerator and denominator assessment...........................................................................50Numerator assessment....................................................................................................52

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Denominator assessment ................................................................................................55Scientific studies on vaccination coverage ..........................................................................59Vaccine safety monitoring ...................................................................................................60Studies on influenza vaccine safety and vaccine effectiveness...........................................62

Section IV: VACCINE PROCUREMENT AND DELIVERY..............................................................68Section V: PROMOTING SEASONAL INFLUENZA VACCINATION ..............................................81

Communication with general public....................................................................................81Communication with health professionals ..........................................................................84

Section VI: USE OF ANTIVIRAL AGENTS FOR TREATMENT AND CHEMOPROPHYLAXIS OFINFLUENZA ...............................................................................................................................88

Treatment ............................................................................................................................89Post exposure prophylaxis ...................................................................................................91Pre-exposure prophylaxis ....................................................................................................91Control of influenza outbreaks ............................................................................................92

Section VII: Technical support from ECDC and overall comments ..........................................95Limitations................................................................................................................................95Summary ..................................................................................................................................96Conclusions ..............................................................................................................................99Recommendations .................................................................................................................101References .............................................................................................................................102Annex 1. Questionnaire .........................................................................................................103Annex 2. Glossary of terms used in questionnaire ................................................................149Annex 3. The draft template for country specific profile ......................................................150

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Abbreviations

ECDC European Centre for Disease Prevention and ControlEEA European Economic AreaEU European UnionGPs General PractitionersHCWs Health Care WorkersNAP National Action PlanMoH Ministry of HealthMSs Member StatesVENICE Vaccine European New Integrated Collaboration EffortCINECA Consortium of University, Bologna, ItalyVC Vaccination CoverageWHO World Health Organization

Acknowledgments

The VENICE Project would like to take this opportunity to thank all the gatekeepers, contactpoints, members of VENICE consortium and ECDC colleagues for their contribution to thisstudy and report. The time generously provided by each person in answering thequestionnaire and subsequent follow-up queries is greatly appreciated.

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ISO 3166-1 Country Codes

AT AustriaBE BelgiumBG BulgariaCY CyprusCZ Czech RepublicHR CroatiaDK DenmarkEE EstoniaFI FinlandFR FranceDE GermanyGR GreeceHU HungaryIS IcelandIE IrelandIT ItalyLV LatviaLI LiechtensteinLT LithuaniaLU LuxembourgMT MaltaNL The NetherlandsNO NorwayPL PolandPT PortugalRO RomaniaSK SlovakiaSI SloveniaES SpainSE SwedenUK United KingdomENG EnglandWL WalesNI Northern IrelandSC Scotland

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VENICE National Gatekeepers and Contact Points

Austria Elisabeth KanitzBelgium Pierre Van Damme, Martine Sabbe, Tine GrammensBulgaria Mira Kojouharova, Radosveta Filipova,Czech Republic Jan Kyncl, Dr. Havlickova, Bohumir KrizCyprus Chrystalla Hadjianastassiou, Soteroulla SoteriouCroatia Vesna Visekruna Vucina, Bernard KaićDenmark Palle Valentiner-Branth, Tyra Grove KrauseEstonia Natalia Kerbo, Irina FilippovaFinland Hanna Nohynek, Tuija LeinoFrance Daniel Levy-Bruhl, Isabelle Bonmarin, Emmanuel

Belchior, Jean Paul Guthman , Eliane VanheckeGermany Ole WichmannGreece Theano Georgakopoulou, Theodora StavrouHungary Zsuzsanna MolnàrIceland Thorolfur GudnasonIreland Suzanne CotterItaly Fortunato D’Ancona, Cristina GiambiLatvia Larisa Savrasova, Jurijs PerevoscikovsLithuania Greta GargasieneLiechtenstein Marina Jamnicki AbeggLuxemburg Serge KripplerMalta Tanya MelilloThe Netherlands Alies van LierNorway Berit FeiringPoland Iwona Paradowska-StankiewiczPortugal Teresa FernandesRomania Rodica Popescu, Aurora StanescuSlovakia Helena HudecovaSlovenia Marta Grgic VitekSpain Aurora LimiaSweden Ingrid UhnooUnited Kingdom- England Richard PebodyUnited Kingdom-Northern Ireland Brian Smyth, Naomh GallagherUnited Kingdom- Scotland Jim McMenaminUnited Kingdom- Wales Simon Cottrell

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SummaryIn Europe, influenza occurs in regular annual epidemics in the winter season. Annualinfluenza epidemics are associated with high morbidity and mortality. Severe illness andcomplications are more common in certain risk groups; these include those with otherchronic medical conditions like diabetes mellitus, immunosuppression, or cardiovascularand respiratory diseases, older individuals (often classified as 65 years of age andolder). The main public health intervention to prevent influenza is influenza vaccination.

The aim of this survey was to update the data on seasonal influenza immunisation policychanges and to obtain vaccination coverage data in the European Union (EU) member states(MSs) and European Economic Area (EEA) countries (Norway, Iceland, and Liechtenstein) forthe 2012-13 influenza season.

A standardised questionnaire was developed and an electronic-based survey was designed.The survey was rolled out in March 2014. Gatekeepers in each MS entered data directly on-line.Of 34 countries (represents 28 EU MSs, with the UK countries providing country specificdata) invited to participate in the survey 33 responded (AT did not respond).

Of 33 responding countries 25 countries had influenza vaccine recommendations for thoseaged 65 years and older. DE,GR, IS and NL recommended vaccination for those aged 60years and older, MT and PL recommended vaccination for those aged 55 years and older; inIE for those aged 50 years and older; in SK vaccine was recommended for those aged 59years and older. Seven countries recommended vaccine for different ages ofchildren/adolescents <18 years of age: two of them (EE,PL) for children of all ages; LV and SIfor children aged >6 months- 2years; FI >6months -3 years; MT->6 months-5 years and SKfor children aged >6 months – 12 years.

Of 33 responding countries 32 recommended influenza vaccine for HCWs; 25 of these hadrecommendations to vaccinate all HCWs; seven recommended vaccination for only someHCWs. Approximately one-third of MSs recommended vaccination for those working inessential (n=7), military (n=11) and veterinary (n=7) services, or for people working in thepoultry (n=11) or swine (n=7) industry workers.

In all 33 counties people with chronic pulmonary, cardiovascular and renal diseases wererecommended influenza vaccine; vaccine was recommended for those with haematologicaldisorders in 30 countries; metabolic disorders and immunosupresssion due to disease ortreatment in 32 countries; in 30 countries vaccine was recommended for individualssuffering from hepatic diseases; 17 countries recommended vaccine for those on long-termaspirin use (children <18 years old). In twenty-eight countries individuals with HIV/AIDSwere also recommended vaccine. Fifteen countries had recommendations to vaccinatethose with morbid obesity.

Of 33 responding countries, 30 recommended vaccination of pregnant women. Twenty-eight countries recommended vaccination of all pregnant women; three countriesrecommended vaccine only for those pregnant women with additional clinical risk. Twenty-

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two of 31 countries recommended influenza vaccination for pregnant women in anytrimester of pregnancy.

Vaccination coverage measured by administrative or estimated by survey methods for theseason 2012-13 was known in 26 countries for older populations (those aged 55, 60 and 65years and older) and ranged from 1.0% (EE) to 77.4% (SC); median 45%. The coverageamong health care workers was known in 13 countries, ranging from 9.5% (PL) to 45.6%(UK-ENG); median 28%. The coverage for clinical risk groups was known in nine countriesranging from 28% (PT) to 80.2% (UK-NI); median 50%. The coverage for pregnant womenwas known in ten countries: ranging from 0.2% (LT) to 64.6% for all pregnant women in UK-NI; median 16%. The coverage for residents of long-stay care facilities was available in threecountries: 71.1% in SK, 73% in IE and 89% in PT.

In conclusion, results of the survey indicate that recommendations for influenza vaccinationexist in most of the countries for the main clinical risk groups, pregnant women and HCWs inaddition to the older population groups. There is discrepancy between havingrecommendations and the ability to report on vaccination coverage for clinical risk groups,pregnant women and HCWs. Although there is widespread consensus that the olderpopulation groups should be vaccinated, vaccination coverage for the elderly is lagging inmost of the countries and it is unlikely that EU target (75% uptake) will be met in 2014/15.Countries should strive to strengthen influenza vaccination coverage monitoring systems forall of those population groups that are targeted for seasonal influenza vaccine. Thosecountries that do not monitor vaccination coverage among older population groups areencouraged to do so.

Background

Influenza is a contagious viral respiratory infection, which typically occurs as epidemicsduring the winter months in temperate zones. Although the illness caused by influenza isusually self-limiting, even in those outside recognised risk groups, it can cause considerableimpact on an individual’s daily life. At a population level, large numbers of cases with mild tomoderate illness increase demands on health services and decrease productivity in theworkforce, with associated economic cost and social disruption [1-3]. The number of peopleaffected varies from year to year among countries, making it hard to predict the annualnumber of deaths or economic impact.

Annual influenza epidemics are associated with high morbidity and mortality. The EuropeanCentre for Disease Prevention and Control (ECDC) estimates that on average nearly 40,000people die prematurely each year from influenza in countries of the European Union(EU)/European Economic Area (EEA) covered by Vaccine European New IntegratedCollaboration Efforts (VENICE). VENICE covers all EU/EEA countries except Liechtenstein [4].Death has been reported in 0.5–1 per 1,000 cases of influenza, with the highesthospitalisation rates occurring among children less than two years of age and individuals≥65 years in United States [5]. The most effective single public health intervention tomitigate and prevent seasonal influenza is vaccination [6]. Unlike the situation for mostchildhood vaccines, the European policy for influenza is protection of those at higher risk,

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either directly by vaccinating them, or indirectly by vaccinating those who are likely to infectthem (healthcare workers (HCWs) and pregnant women). Vaccination of pregnant womenprotects women during, and immediately after, pregnancy and also decreases the risk totheir infant [7].

The primary indicators of success in implementation of vaccination programmes are highuptakes reported among the specific groups, i.e. the proportion of specific targetpopulations who have been vaccinated. In December 2009, the European Councilunanimously recommended that EU countries adopt and implement national action plans toachieve 75% influenza vaccination coverage in all at-risk groups by the influenza season of2014/15 [8]. The selection of risk groups followed guidance from ECDC andrecommendations of the World Health Organization (WHO): ‘older’ individuals (oftendefined as aged ≥65 years) and people of all ages above six months with underlying medicalconditions [9-11], referred to in this report as clinical risk groups. This EU recommendationencouraged countries to adopt and implement national, regional or local action plans orpolicies to improve seasonal influenza vaccination including among HCWs and to measurecoverage in all risk groups. Countries were also encouraged to report on a voluntary basis tothe European Commission on the implementation of the recommendation. ECDC-supportedVENICE surveys have been identified as being the most effective way of doing this withoutplacing additional reporting burdens on countries [12,13].

ObjectivesAim of the studyThe aim of this survey was to update the data on seasonal influenza immunisation policyprovided in a previously conducted survey and to obtain vaccination coverage data in theEuropean Union (EU) member states (MSs) and European Economic Area (EEA) for 2012-13influenza season.

Specific objectives• To assess seasonal influenza immunisation programmes for the 2012-13 season;• To identify country specific recommendations for different risk groups for the 2012-

13 season;• To obtain the vaccination coverage data for 2012-13 influenza season for age, risk,

targeted groups and total population;• To obtain information in relation to payment for seasonal influenza vaccine during

the 2012-13 season.

Methodology

Study DesignThe electronic survey was developed on a web-based platform with protected access fornominated gatekeepers from each MS. This survey was a collaborative study between theEuropean Centre for Disease Prevention and Control (ECDC), VENICE Project and EuropeanUnion (EU) and European Economic Area (EEA) Member States (MS). Currently in theVENICE project there are 28 EU and three EEA (LI, NO and IS) participating countries. This isthe first year in which Croatia (HR) has participated as it joined the EU in July 2013. Surveyfor United Kingdom was completed for each part of the country: Scotland (SC), Northern

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Ireland (NI, Wales (WL) and England (ENG). Liechtenstein (LI) also was invited to participatein this survey.

Data collectionA standardised questionnaire was developed using predominantly close-ended questions.Information was sought on population groups recommended influenza vaccination (age,occupation, medical risk or other social situation), whether countries had mechanisms inplace to monitor influenza vaccine uptake, the method used to monitor uptake, recentvaccination coverage results (by population group, season), payment and administrationcosts for vaccine, health care, or other, setting where vaccine was typically administered,methodology used to promote influenza vaccines and how this activity is supported andfinally, information was sought on planned policy or operational changes over the nextcouple of years (Appendix 1).

For the first time in this seasonal influenza vaccination survey information was also soughton antiviral agents recommended and used in MSs.

Data handlingThe electronic questionnaire was developed and placed on VENICE website in February 2014by CINECA, which was available for all participating countries (http://venice.cineca.org). Theelectronic questionnaire was filled in March by gatekeepers in each country and saved. Non-responders were followed up. The data were analysed in April 2014.

Data processingGatekeepers in each MS entered data directly on-line.

Pilot studyThe questionnaire was pilot tested by four VENICE project-leading partners: Italian IstitutoSuperiore di Sanità (ISS), the French Institut de la Veille Sanitare (INVS), CINECA Consortiumof University, Bologna, Italy ,Polish National Institute of Public Health, German Robert KochInstitute (RKI), Danish Statens Serum Institute (SSI) and the Irish Health ProtectionSurveillance Centre (HPSC). The piloting of the study was undertaken in late January 2014.After the pilot study, the questionnaire was reviewed and amended as necessary.

Study timeMSs were asked to complete the electronic questionnaire between 3rd and 17th of March2014. The accompanying letter to MSs explained the objectives and rationale of the study.For those countries who did not respond survey completion was extended by 24th of March.Countries which not responded to the data collection extension deadline were contactedindividually.

Data analysisThe data were analysed using MS-Excel and STATA.The main indicators analysed included:

1. Description of population groups recommended influenza vaccination (age,occupation, medical or social condition risk);

2. Monitoring of influenza vaccine uptake (by country and methodology);

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3. Vaccination coverage results by population group, season and method used tomeasure;

4. Costs associated with programme and who pays (state or individual) and how thisimpacts on uptake;

5. Usual venues for influenza vaccination;6. Methodologies used to promote influenza vaccines and how and who supports this

activity.

Expected deliverablesThe expected output of this survey is development of a technical report to inform policymakers at European, EU and national level as well as those working in the field of influenzavaccination programmes in the member states.

Results

Response rate

Of 34 countries 33 responded to the survey. AT did not provide data. Data were validated by26 countries (BE,BG,CY,CZ,HR,DK,EE,FR,DE,GR,HU,IE,IT,LV,LI,LT,NO,PL,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC). Data for Netherlands were validated only for thelast section of this report (section VI: use of antiviral agents for influenza). The remainingfive countries (FI, LU, MT, IS, PT, UK-WL) did not validate their data.

Section I: GROUPS RECOMMENDED SEASONAL INFLUENZA VACCINATION (2012-13influenza season) BY NATIONAL/REGIONAL AUTHORITY

Influenza immunisation policy

All 33 responding countries (CY,BE,BG,CZ,DE,DK,EE,FI,FR,GR,HR,HU,IE,IS,IT,LT,LU,LV,MT,NL,NO,PL,RO,SE,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,LI,SK,PT) indicated that there are nationalseasonal influenza vaccination recommendations (e.g. age and target grouprecommendations and guidelines) available in their countries.

Four countries indicated that a National Action Plan to improve vaccination coverage forseasonal influenza vaccination as recommended by EC 22/12/2009http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:348:0071:0072:EN:PDFwas adopted and three countries reported that they had a plan that was developedpreviously and updated according to EC recommendation; in addition, 15 countries reportedthat although such plan was not formally developed they did have a policy in place (table 1).Eight countries, which indicated that a national Action plan was developed, provided thelink to the published document on a national website (table 1a).

Table 1. Availability of national action plan to improve vaccination coverage for seasonalinfluenza in EU/EEA countries in 2012-13 influenza season. National seasonal influenzavaccination survey, March 2014 (n=33)

Countries Total

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Yes, plan was adopted CZ,NL,UK-WL,IE 4Yes, plan was developed previously andupdated according EC recommendation

IS,PL,UK-ENG 3

A plan was not developed, but a respectivepolicy is in place

BE,DE,DK,FI,FR,HR,HU,LV,MT,NO,UK-NI,LI,PT,UK-SC,ES

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Plan is under development BG,CY 2No need to adopt as vaccination coveragemeet EC/WHO targets

- 0

Plan not adopted EE,GR,IT,LT,LU,RO,SE,SI,SK 9

Table 1a. Link to the National action plan on website. National seasonal influenzavaccination survey, March 2014 (n=8)Country Link to the websiteCZ http://www.mzcr.cz/Verejne/dokumenty/narodni-akcni-plan_5329_1092_5.htmlIS https://venice.cineca.org/uxmr/INF/download.php?nome_real_file=Q3_2_QUID

_113_PROGR_1_VISITNUM_4_ESAM_3_VPROGR_0.pdfIE http://www.immunisation.ie/en/HotTopics/Text_17237_en.htmlNL www.rivm.nlPL http://www2.mz.gov.pl/wwwmz/index?mr=m10&ms=688&ml=pl&mi=688&mx=

0&ma=13290UK –ENG

http://webarchive.nationalarchives.gov.uk/20130107105354/http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/documents/digitalasset/dh_133964.pdf

UK-WL https://venice.cineca.org/uxmr/INF/download.php?nome_real_file=Q3_2_QUID_133_PROGR_1_VISITNUM_4_ESAM_3_VPROGR_0.pdf

UK-SC http://www.sehd.scot.nhs.uk/cmo/CMO(2012)06.pdf

Documents used elaborating/updating policy

The following documents, presented in the table 2 by country, were used when elaboratingand updating recommendations for seasonal influenza vaccination.

Table 2. The documents used elaborating /updating vaccination policy for seasonal influenzain EU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccinationsurvey, March 2014 (n=33)

Document was used Document was notused

Council recommendation onseasonal influenza vaccination22/12/2009 http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:348:0071:0

BE,BG,HR,CZ,DK,EE,DE,GR,HU,IS,IE,IT,LV,LT,LU,NO,PL,SI,ES,SE,UK-ENG,UK-NI,UK-SC,CY,LI,SK,PT

FR,MT,NL,RO,UK-WL,FI

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072:EN:PDFECDC GUIDANCE Priority riskgroups for influenza vaccination,2008(http://www.ecdc.europa.eu/en/publications/Publications/0808_GUI_Priority_Risk_Groups_for_Influenza_Vaccination.pdf)

BE,BG,HR, HU,CZ,DK,EE,GR,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,SI,ES,SE,UK-NI,UK-SC,FI,CY,LI,SK,PT

FR,DE, RO,UK-ENG,UK-WL

ECDC scientific advice onseasonal influenza vaccination ofchildren and pregnant women2012(http://www.ecdc.europa.eu/en/publications/publications/seasonal%20influenza%20vaccination%20of%20children%20and%20pregnant%20women.pdf)

BE,HR,HU,DK,EE,GR,IS,IE,IT,LV,LU,MT,NO,PL,SI,ES,SE,UK-NI,UK-SC,LI,SK,PT

BG,CZ,FR,DE,LT,NL,RO,UK-ENG,UK-WL,FI,CY

European Medicine Agency(Summary of productcharacteristics): e.g.http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001101/WC500103709.pdf

BE,BG,HR,DK,EE,DE,GR,IS,IE,IT,LV,LU,NO,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,LI,SK,PT

CZ,FR,HU,LT,MT,NL,PL,RO,SI,CY

Vaccines against influenza WHOposition paper – November 2012http://www.who.int/wer/2012/wer8747.pdf

BE,BG,HR,DK,EE,DE,GR,IS,IE,IT,LV,LT,LU,MT,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,LI,SK,PT

CZ,FR,HU,NL,UK-WL,FI,CY

Others, please specifya HR,FR,IE,ES,SE,UK-WL,CY,LI,PT

BE,BG,CZ,DK,EE,DE,GR,HU,IS,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,UK-ENG,UK-NI,UK-SC,FI,SK

aCY- CDC.aHR, FR, SE -Scientific literature and meta-analyses.aIE-National Immunisation Advisory Committee Guidance.aES-Previous recommendations and specific recommendations at regional level.aUK-WL- UK DH Immunisation Against Infectious Diseasehttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/239268/Green_Book_Chapter_19_v5_2_final.pdf

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Recommendation for entire population

The national policy document (guidelines and recommendations) recommends seasonalinfluenza vaccine to all individuals > 6 months of age (entire population) in three countries(EE,PL,SI); in 30 countries (BE,BG,HR,CY,CZ,DK,FI,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,PT,RO,SK,ES,SE, UK-ENG,UK-NI,UK-SC,UK-WL) there is no such recommendation.

Age groups recommended influenza vaccine

Of 33 responding countries, seven recommended seasonal influenza vaccine to healthychildren or adolescents (LV,SI,FI,MT,PL,EE,SK); all countries also had recommendation tovaccinate older age groups. However the exact age at which children and older individualswere recommended vaccine differed between countries both: for adults (from ≥50 to ≥65years) and children and adolescents (table 3).

Table 3. Age groups recommended seasonal influenza vaccine in EU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)

Countries TotalChildren and adolescents

No recommendation for healthy childrenor adolescents of any age

BG,BE,HR,CZ,DK,FR,DE,GR,HU,IS,IE,IT,LT,LU,NL,NO,RO,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,PT

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Recommended for all children oradolescents:

LV,SI,FI,MT,PL,EE,SK 7

≥6 months - 24 months of age LV, SI 2≥6 months - 36 months of age FI 1≥6 months - 59 months of age MT 1≥ 6 months – 12 years of age SK 1≥6 months - 18 years of age PL, EEd 2

AdultsRecommended for all adults ≥18 years EEd 1Recommended for some age groups for alladults:

≥50 years BEa, IEb 2≥55 years MT,PL 2≥59 years SK 1≥ 60 years DE,GR,IS,NL 4≥ 65 years RO, BEa,BG,EE,HR,CZ,DK,FI,FR,HU, IEb,

IT,LV,LT,LU,NO,SI,ESc,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,PT

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a The guidelines recommend vaccine for those ≥65 years of age and they belong to the first priority group forreceiving the influenza vaccine; the guidelines also mention explicitly that the vaccine is also useful for healthypersons aged 50 and older.b NITAG recommends vaccine for those ≥50 years but the national influenza programme specifies ≥65 years,nationally.c The recommendation at national level is for those ≥65 years of age; however 10 out of 19 regionsrecommend vaccine for those ≥60 years of age.d Vaccination against seasonal influenza is recommended for all population of EE aged ≥6 months.

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For the 2012-13 season only FI introduced changes in relation to seasonal influenzavaccination recommendations in comparison to recommendations for influenza season2011-12: “if a person belongs to the close vicinity of someone to whom falling ill withinfluenza would be detrimental, such persons are offered vaccination”. There were nochanges in recommendations with regard to age groups in any other of the other 32countries (BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT).

Payment scheme and funding mechanism for age groups

Data on payment scheme and funding mechanism for seasonal influenza vaccine withregard to recommended age groups (children and adolescents and adults) by country arepresented in tables 4 and 4a.

Table 4. Payment scheme and funding mechanism for seasonal influenza vaccine withregard to recommended age groups in EU/EEA countries in 2012-13 influenza season.National seasonal influenza vaccination survey, March 2014

Payment scheme For vaccineitself

For vaccineadministration

Children and adolescents (n=7)National health service MT,FI LV,MTRegional health service - FINational health service;Out of pocketa;Parent/guardian employer

LV -

Out of pocket SI SIOut of pocket;Parent/guardian employer;

EE EE

Private insurance;Out of pocket

PL -

National insurance scheme;Private insurance

- PL

National insurance scheme SK SKAdults (n=33)

National health service FI,HR,DK,IS,LT,MT,NL,UK-ENG,UK-NI,ROUK-SC,UK-WL,IT

DK,LT,MT,NL,UK-ENG,UK-NIUK-SC,UK-WL,RO,IT

National insurance scheme CZ,FR,GR,SI,SK HR,CZ,GR,LU,SK

National health service;Out of pocket

LV -

National insurance scheme; LU -

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National health service;National health service;Out of pocket;Employer;For those aged 50-64 years without health risk oremployment recommendation than the individual mustpay for vaccine

IE IE

National insurance scheme;Out of pocket

BE BE

National insurance scheme;Private insurance;Employer

DE DE

Government (Public Health Service) HU -No extra pay of administration of flu vaccine - HUOut of pocket BG,NO BG,IS,LV,NO,SIPrivate insurance;Out of pocket;Employer

PL -


- PL,FR

Regional health service ES ES,FIRegional health service;Out of pocket;Varies with regions: in some regions, the vaccinee ischarged a symbolic amount (approximately 10€) forvaccine & vaccination

SE SE


CY

National health service;Out of pocket;Private insurance

- CY

Private insurance; LI LI37% reimbursement; vaccine free for ≥65 years andother risk groups

PT

National health service;paid if administered in pharmacies

PT

Out of pocket EE EEa Out of pocket means not reimbursed, paid by vaccinee.

Table 4a. Co-payment for vaccine and its administration (vaccination) mechanism forinfluenza vaccine with regard to recommendation to age groups in EU/EEA countries in2012-13 influenza season. National seasonal influenza vaccination survey, March 2014

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CountryChildren and adolescents (n=7)

Co-payment for vaccineThere is no co-payment EE,MT,PL,SI,FI,SKCo-payment exista LVa

Co-payment for administrationThere is no co-payment EE,LV,MT,PL,SI,FI,SKCo-payment exist -

Adults (n=31)Co-payment for vaccine

There is no co-payment EE,FI,BG,HR,DK,FR,DE,GR,HU,IS,IE,LT,LU,MT,NL,NO,PL,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,SK

Co-payment existb BE, CZ,LV,SE,CY,LI,PTCo-payment for administration

There is no co-payment EE,FI,BG,HR,CZ,DK, DE,GR,HU,IS,IE,LV,LT,MT,NL,NO,PL,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,SK,PT

Co-payment existc BE,LU,SE,CY,LI, FRIT- No data for adults.a, b LV-50%.b, c BE- Partly refunded.b, c CY- There is a co-payment in cases they are eligible to "free" health care by the public. The others pay outof pocket or by private insurances.bCZ-Only cheapest vaccine is covered from insurance for people ≥65 of age. For other vaccine/s , there is needto pay the difference.b, c LI-10% of the cost.bPT- 37%reimbursment NHS.b, c SE- In some regions, the vaccinee is charged a symbolic amount (approximately 10€) for vaccine &vaccination.cLU- 10% of the doctor's visit price.c FR: 35% of the vaccine administration cost is paid by the patient which are refunded if the patient has aprivate insurance (most of the time).

Comment/s indicated on issues with reimbursement of cost of vaccine, or its administration, that mayinfluence vaccination coverage with regard to age groups:PL- Local government reimbursement of cost of vaccine for children and adolescents and for those ≥65 yearsof age.SK- It is the decision of insurance companies whether they offer the vaccination free of charge for all theirclients or only to groups recommended in the legislation.DE- New tender systems in some of the federal states, which are new to the physicians and not yet fullyaccepted. Some used vaccines on the market but not in the tender; then no reimbursement.IE-For some adults they may have to pay if they are not covered by national health service (usually incomedependent).

Clinical risk groups

All 33 survey participating countries reported that seasonal influenza vaccine wasrecommended for patients with chronic pulmonary, cardiovascular and renal diseases.Thirty countries recommended vaccination of individuals with hepatic disease andhaematological disorders; and in 32 countries individuals with metabolic disorders andimmunosupression due to diseases or treatment also had such recommendation. Twenty-

18

eight countries recommended vaccination of individuals with HIV/AIDS. Vaccine for thosewith morbid obesity was recommended in fifteen countries (table 5).

Table 5. Clinical risk groups recommended influenza vaccine in EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)

Medical condition/risk Recommendeda Norecommendationb

Chronic pulmonary (such as chronicobstructive pulmonary disease, cysticfibrosis, asthma) disease

FI,BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

Cardiovascular (such as congenitalheart disease, congestive heart failureand coronary artery disease, excepthypertension) disease

FI,BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

Renal disease FI,BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

Hepatic disease FI,BE,BG,HR,CZ,DK,EE,FR,DE,HU,IS,IE,IT,LV,LU,MT,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

GR,LT, NL

Hematological disorders (such as sicklecell disease)

FI,BE,BG,HR,DK,EE,FR,DE,GR,HU,IS,IE,IT,LT,LU,MT,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

CZ,LV,NL

Metabolic disorders (such as inheritedmetabolic disorders and mitochondrialdisorders, including diabetes mellitus)

FI,BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

LT

Immunosuppression due to disease ortreatment (including asplenia/ splenicdysfunction, organ transplantation,cancer, but other than HIV/AIDS)

FI,BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT

LV

HIV/AIDS FI,BE,BG,HR,CZ,DK,EE,FR,DE,GR,IS,IE,IT,LU,MT,NL,NO,PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,PT

HU,LV,LT,SE,SK

19

Chronic neurologic diseases orneuromuscular conditions ( e.g.including disorders of the brain, spinalcord, peripheral nerve, and musclesuch as cerebral palsy, epilepsy (seizuredisorders), stroke, intellectual disability(mental retardation), moderate tosevere developmental delay, musculardystrophy, or spinal cord injury).

FI,BE,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LU,MT,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,PT

BG,LV,LT,NL,SK

Long-term aspirin use (in children up to18 years old)

FI,BE,HR,EE,GR,HU,IS,IE,IT,LV,LU,PL,SI,ES,CY,PT,NL

BG,CZ,DK,FR,DE,LT,MT,NO,RO,SE,UK-ENG,UK-NIUK-SC,UK-WL,LI,SK

Any condition that can compromiserespiratory function

BE,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LT,LU,NL,PL,SE,UK-SC,CY,FI,SK,PT

BG, ES,LV,MT,NO,RO,SI,UK-ENG,UK-NI,UK-WL,LI

Morbid obesity (Body Mass Index (BMI)>40)

FI,HR,DK,EE,FR,HU,IS,IE,IT,NO,PL,ES,SE,CY, PTc

BE,BG,CZ,DE,GR,LV,LT,LU,MT,NL,RO,SI,UK-ENG,UK-NI,UK-SC, UK-WL,LI,SK,

a”Recommended” is defined here, and in the following questions, asthe existence of a specific writtenrecommendation in an official policy document that this population group should receive seasonal influenzavaccine.b “No recommendation” defined here, and in the following questions, as no specific written recommendationis made in the official policy document regarding whether this population group should be vaccinated or not.b Recommended for those BMI ≥30.

Other chronic diseases or conditions recommended influenza vaccine:DK- recommended for any other condition where a doctor considers there is an increasedrisk of severe outcomes of influenza.SE- children with certain other conditions: include multiple handicaps, metabolic disorders, Down's syndromeand severe asthma (4th degree).The recommendation does not cover all metabolic disorders - only diabetes.Persons with HIV who are immunosuppressed are thereby included in the risk Group "Immunosuppression".NL- persons with a mental handicap living in residential homes.FI- Any condition the physician or public health nurse thinks poses a risk for serious influenza. We no longerprovide an exhaustive list of diagnostic entities which qualify for vaccination; instead the decision to vaccinatelies with the clinician and bases more on individual risk assessment.

In the 2012-13 season FI, FR and PL introduced changes in relation to seasonal influenzavaccination recommendations for clinical risk groups in comparison to influenza season2011-12. In FI it was decided not to have exhaustive lists of conditions but rather moredecision making responsibility was given to the treating physician/ public health nurse. In FRhepatic diseases were added to the list of chronic diseases and conditions for whichinfluenza vaccine was recommended. In PL there was a refinement of clinical indications,individual and epidemiological.There were no changes in recommendations with regard to clinical risk groups in any of theother 30 countries (BE,BG,HR,CZ,DK,EE,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,CY,LI,SK,PT,SE).

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Payment scheme and funding mechanism for clinical risk groups

Data relating to payment scheme and funding mechanisms for seasonal influenza vaccine,with regard to recommended clinical risk groups by country, are presented in tables 6 and6a.

Table 6. Payment scheme and funding mechanism for influenza vaccine and vaccineadministration for clinical risk groups in EU/EEA countries in 2012-13 influenza season.National seasonal influenza vaccination survey, March 2014 (n=33)

Payment scheme For vaccine itself For vaccineadministration

National health service FI,HR,DK,IS,IE,IT,LT,MT,NL,UK-ENG,UK-NI,UK-SC,UK-WL

DK,IT,LT,MT,NL,UK-ENG,UK-NI,UK-SC,UK-WL

National insurance scheme FR,GR,SI,SK HR,CZ,GR,LU,SK,FROut of pocketa BG,NO BG,IS,LVb,NO,SIRegional health service ES ES,FINational insurance scheme; Private insurance DE DE,PLPrivate insurance;Out of pocket;Employer

PL -

National health service;Out of pocket;Employer

- IE


LVb

National insurance scheme;National health service

LU -

National insurance scheme;The list of chronic diseases to be reimbursedfrom insurance is shorter than the list ofchronic diseases from national vaccinerecommendation

CZ -

National insurance scheme;Out of pocket

BE BE

Out of pocket EE EEGovernment (Public Health Service) HU HUMinistry of Health, Public Sector RO RORegional health service;Out of pocket;Varies with regions: In some regions, avaccinee belonging to a clinical risk group wascharged a symbolic amount (approximately10€) for vaccine & vaccination

SE SE

National health service;Out of pocket;Private insurance

CY CY

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Private insurance LI LI37% reimbursment;vaccine free for ≥65 years and other riskgroups

PT -

National health service;paid if administered in pharmacies

- PT

a Out of pocket means not reimbursed, paid by vaccinee.b All persons with any kind of immunodeficiency (including HIV/AIDS) can get 50% reimbursement of the costof the vaccine.

Table 6a. Co-payment for vaccine and administration of influenza vaccine (vaccination) forclinical risk groups in EU/EEA countries in 2012-13 influenza season. National seasonalinfluenza vaccination survey, March 2014 (n=33)

CountryCo-payment for vaccine

There is no co-payment EE,BG,HR,DK,FI,FR,DE,GR,HU,IS,IE,IT,LT,LU,MT,NL,NO,PL,RO,SK,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL

Co-payment exista BE,CY,CZ,LV,LI,PT,SECo-payment for administration

There is no co-payment EE,BG,HR,CZ,DK,FI,FR,DE,GR,HU,IS,IE,IT,LV,LT,MT,NL,NO,PL,PT,RO,SK,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL

Co-payment existb BE,CY,LI,LU,SEa,bBE- Yes, partly refunded.a, bCY- Yes, there is a co-payment in cases they are eligible to "free" health care by the public. The others payout of pocket or by private insurances.aCZ- Yes, only cheapest vaccine is covered from insurance for people with chronic conditions. For othervaccine, you have to pay the difference.aLV- Yes 50%.a, bLI- Yes, 10% of the cost.aPT- Yes, 37% reimbursement NHS.a, bSE- Yes, In some regions, a vaccinee belonging to a clinical risk group was charged a symbolic amount(approximately 10€) for vaccine & vaccination.b LU- Yes, 10% of the doctor's visit price.

Pregnancy related vaccination

Of 33 responding countries 30 indicated that influenza vaccine was recommended forpregnant women. Twenty eight countries recommended vaccination of all pregnant womenand two countries (HR,NL) recommended it for those pregnant women with an additionalclinical indication only. Twenty-two countries recommended vaccine at any stage ofpregnancy and nine countries recommended vaccine in either the 2nd or 3rd trimester (table7).

Table 7. Pregnancy related influenza vaccine recommendation EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)

Pregnancy related vaccination Countries TotalNo recommendationa BG,SK, MTc 3Recommendedbb for all FI,BE,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT

LU,NO,PL,RO,SI,ES,SEd,UK-ENG,UK-NI,28

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UK-SC,UK-WL,CY,LI,PTRecommended only for those withother clinical risk indication

HR,NL 2

Stages of pregnancy (n=31)Any trimester FI,HR,CZ,DKe,EE,FR,GR,HU,IS,IE,LV,LT,MT,NL,

PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL22

Either 2nd or 3rd trimester BE,DEe,IT,LU,NO,SE,CY,LI,PT 9Postpartum women if not vaccinated during pregnancy f (n=31)

No recommendation BE,CZ,DK,DE,GR,HU,IS,IT,LV,LT,LU,NO,PLg,ROSI,ES,SE,UK-ENG,UK-NI,UK-WL,CY,PT, MTc

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Recommended for all EE,LI 2Recommended only for those withother clinical risk indication

HR,FR,IE,NL,UK-SC,FI 6

a “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.b “Recommended” defined here and in the following questions as the existence of a specific writtenrecommendation in the official policy document that this population group should receive seasonal influenzavaccine.c There is no official recommendation for influenza vaccination to pregnant women; however those pregnantwomen who are interested in taking the vaccine are encouraged to do so; vaccine is not provided free ofcharge.dSE- Recommended for all women, pregnant or not, belonging to the above mentioned clinical risk groups ANDthose otherwise healthy pregnant women who were not vaccinated with Pandemrix 2009-2010.e Vaccination is recommended to all pregnant women in the 2nd and 3rd trimester; to women with otherclinical risk indication also in the 1st trimester.f Within 6 weeks after delivery.g In national schedule recommendation contains pregnant women and women if they plan to be pregnant,however experts’ recommendation include also women in the postpartum period.

Of 30 countries (one country did not respond), where influenza vaccine is recommended topregnant women, 15 indicated that the most common venue for vaccination are generalpractitioners; five countries in addition to general practitioners specified also maternityout-patient and antenatal clinics (table 8).

Table 8. The main venue/s where influenza vaccination is performed for pregnant women.National seasonal influenza vaccination survey, March 2014 (n=30)

Countries TotalGeneral practitioners/Family doctors BE,HR,DK,EE,HU,IE,LV,LT,

MT,NL,PL,RO,SE,UK-NI,UK-SC

15

Maternity out-patient clinic;General practitioners/Family doctors;Antenatal clinic

DE,IS,UK-ENG,UK-WL,ES 5

General practitioners/Family doctors;Public health centers

NO 1

General practitioners/Family doctors;Regional Units of NIPH

SI 1

General practitioners/Family doctors; IT 1

23

Vaccine services in Local Health UnitsMaternity out-patient clinic;General practitioners/Family doctors

GR 1

Maternity out-patient clinic;General practitioners/Family doctors;Obstetricians private practices

LU 1

Maternity out-patient clinic;Well-baby clinic;General practitioners/Family doctors;Antenatal clinic;At the time of delivery (hospital, home or otherclinic setting);Midwifes

FR 1

Well-baby clinic;Antenatal clinic;Post-natal clinic

FI 1

Maternity out-patient clinic;General practitioners/Family doctors;

CY 1

Maternity out-patient clinic;General practitioners/Family doctors;Well-baby clinic;Antenatal clinic;Post-natal clinic

LI 1

Health centres (NHS), pharmacies, private clinics PT 1CZ- No data for venue/s where vaccination for pregnant women is performed.

In the 2012-13 season three countries (GR,LV,SE) introduced changes in relation torecommendations for pregnant women in comparison to influenza season 2011-12. In GRvaccine was recommended to all pregnant women in the 1st trimester in 2012-13; inprevious season it was recommended only for those in the either 2nd or 3rd trimester. In LVpregnancy was added to the list of medical conditions that are recommended influenzavaccination. SE- Otherwise healthy pregnant women that were not vaccinated withPandemrix 2009-2010 were recommended influenza vaccination to gain protection againstH1N1pdm09.

There were no changes in recommendations with regard to clinical risk groups in any otherof 30 countries (BE,BG,HR,CZ,DK,EE, DE,HU,IS,IE,IT,LT,LU,MT,NL,NO,PL,RO,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT,SI,FR).

Payment scheme and funding mechanism for pregnancy related vaccination

Payment scheme and funding mechanism for seasonal influenza vaccine with regard torecommendation to pregnant women by country presented in tables 9 and 9a.

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Table 9. Payment scheme and funding mechanism for pregnant women for influenzavaccination in EU/EEA countries in 2012-13 influenza season. National seasonal influenzavaccination survey, March 2014 (n=30)


National health service FI,HR,DK,IS,IE,IT,LT,MT,NL,UK-ENG,UK-NI,UK-SC,UK-WL

DK,IT,LT,MT,NL,UK-ENG,UK-NI,UK-SC,UK-WL

National insurance scheme FR,GR,SI HR,FR,GR,LUOut of pocketa EE,LU,NO EE,IS,LV,NO,SIRegional health service ES ES,FINational health service;Out of pocket

LV -

National insurance scheme; Out of pocket BE BENational insurance scheme; Privateinsurance

DE DE,PL

Government (Public Health Service) HU -

No extra pay of administration of flu vaccine - HUMinistry of Health, Public Sector RO RO

Private insurance;Out of pocket;Employer

PL -

Regional health service;Out of pocket;Varies with regions: In some regions, thevaccinee was charged a symbolic amount(approximately 10€) for vaccine &vaccination.

SE SE


- IE

National health service;Out of pocket;Private insurance;

CY CY

Private insurance LI LI37% reimbursement;Vaccine free for ≥65 years and other riskgroups

PT -

National health service;Paid if administered in pharmacies

- PT

a Out of pocket means not reimbursed, paid by vaccinee.BG,SK- Not applicable.CZ - No data available.

Table 9a. Co-payment for vaccine and administration of influenza vaccine (vaccination) forpregnant women in EU/EEA countries in 2012-13 influenza season. National seasonalinfluenza vaccination survey, March 2014 (n=30)

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CountriesCo-payment for vaccine

There is no co-payment HR,DK,EE,FR,DE,GR,HU,IS,IE,IT,LT,LU,MT,NL,NO,PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI

Co-payment exista BE,LV,SE,CY,LI,PTCo-payment for administration

There is no co-payment HR,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,MT,NL,NO,PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI,PT

Co-payment existb BE,LU,SE,CY,LIa, b BE-Partly refunded.aLV-Yes 50%.a, b SE-In some regions, the vaccinee was charged a symbolic amount (approximately 10€) for vaccine &vaccination.aPT-37% reimbursement.a, b CY- there is a copayment in cases they are eligible to "free" health care by the public. The others pay out ofpocket or by private insurances.a, b LI- 10% of the cost.bLU-Yes 10% of the doctor's visit price.BG,SK- Not applicable.CZ - No data available.

Comment for issues with reimbursement of cost of vaccine, or its administration, that may influencevaccination coverage:EE-Full cost of vaccine and vaccination paid by vaccinee.IE-For some pregnant women they may have to pay if they are not covered by national health service (usuallyincome dependent).

Health care workers

Of 33 responding countries, 26 reported that influenza immunisation was recommended forall HCWs; six countries recommended vaccination of some HCWs (e.g.outpatient/inpatient/long term care); in DK vaccine was not recommended to HCWs nationally;however most regions and municipalities in DK offer HCW influenza vaccination free ofcharge. Details presented in a table 10.

Table 10. Influenza vaccine recommendations for HCWs in 2012-13influenzaseason.National seasonal influenza vaccination survey, March 2014 (n=33)

Recommendation to HCWs Countries TotalNo recommendation to HCWs DKa 1Recommended to all HCWs BE,BG,HR,CZ,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT

,LU,MT,NL,PL,RO,SI,ES,UK-NIb,UK-SC,FI,CY,LI,

26

Recommended to some HCWs (e.g.outpatient/inpatient/long term care)

NO,SEc,UK-ENG,UK-WLd,SKe,PT 6

Status of vaccination recommendationVoluntary f BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,

LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT

33

Mandatoryg - 0

26

a No national recommendations, but most regions and municipalities offer HCW influenza vaccination free ofcharge.b Available to all HCWs but encouraged for frontline staff.c Only staff caring for persons who are severely immunocomprimised are recommended vaccination.d Seasonal influenza vaccination is recommended for front-line health and social care workers (i.e. those whohave direct contact with patients).e The HCWs having close contact with patients or foci of infection.f”Voluntary” defined here as individual free will (choice) when deciding on seasonal influenza vaccination andthere is no penalty for not getting the vaccine.g “Mandatory” (compulsory, obligatory, authoritatively ordered) defined here as vaccination for which there isa “penalty” for those who refuse seasonal influenza vaccination.

In the 2012-13 season there were no changes in recommendations with regard to clinicalHCWs in any of the 33 countries (BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT) in comparison toinfluenza season 2011-12.

Payment scheme and funding mechanism for HCWs

Data related to payment schemes and funding mechanisms for seasonal influenza vaccinewith regard to recommendations to HCWs, by country, are presented in tables 11 and 11a.

Table 11. Payment scheme and funding mechanism for HCWs in EU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)


Employer NL,NO,SI,SE,LI,SK,PT,DK a

IS,NL,NO,SI,SE,LI,SK,PT,DK a

National health service HR,IS,IE,IT,LT,MT,UK-ENG,UK-SC,FI

IT,LT,MT,UK-ENG,UK-NI,UK-SC

Out of pocketb;Employer

BG,EE,LV,LU,CZc BG,EE,LV,CZc

National health service;Employer

UK-NI,UK-WLd IE, UK-WLd

Regional health service ES ES,FINational insurance scheme;Employer

FR FR,LU

National insurance scheme;National health service

GR -

National insurance scheme;National health service;Regional health service

- GR

National insurance scheme;Out of pocket;Employer;

BE BE

Employer;National insurance scheme;Private insurance

DE DE

27

Government (Public Health Service) HU -No extra pay of administration of fluvaccine

- HU

Ministry of Health, Public Sector RO ROPrivate insurance;Out of pocket;Employer

PL -

National insurance scheme; Privateinsurance

- PL

National insurance scheme; - HRNational health service;Private insurance;Out of pocket

CY CY

a The Employer pay for the vaccine and the administration even if the recommendation is not national.b Out of pocket means not reimbursed, paid by vaccinee.c 100% paid by vaccinee or employer.d The main employer is National Health Service.

Table 11a. Co-payment for influenza vaccine and administration of vaccine (vaccination) forHCWs in EU/EEA countries in 2012-13 influenza season. National seasonal influenzavaccination survey, March 2014 (n=32)


There is no co-payment DE,BG,HR,EE,FR,GR,HU,IS,IE,IT,LV,LT,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,LI,SK,PT,CZ

Co-payment exista BE,LU,CYCo-payment for administration

There is no co-payment DE,BG,HR,EE,FR,GR,HU,IS,IE,IT,LV,LT,MT,NL,NO,PL,ROSI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,LI,SK,PT,CZ

Co-payment existb BE,LU,CYa BE- Partly refunded / sometimes fully covered by employer.a LU- For those who don't get the vaccine by the employer.a, b CY- There is a co-payment in cases they are eligible to "free" health care by the public. The others pay out ofpocket or by private insurances.b BE-Partly refunded.b LU- 10% of the doctor's visit price for the HCWs vaccinated outside of the occupational health services.

Comment for issues with reimbursement of cost of vaccine, or its administration, that may influencevaccination coverage:EE-Full cost of vaccine and vaccination paid by vaccinee. For some HCW vaccines and vaccinations are beingpaid by employer.IE- Health care worker should not have to pay for administration but some reports indicate the possibility thatsometimes they do. We are not sure of the circumstances or if this is a personal choice (different provider).LU- Universal employer payment for the vaccination of HCWs from the hospital sector, variable paymentcoverage from employers for other HCWs.LI- Low uptake, of only 20%.

Other occupational groups

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Among the 33 responding countries, influenza vaccination is recommended for essential(police and firemen) and military services in seven and 11 countries respectively; for poultryindustry workers in 11 countries and for veterinary service workers in seven countries.Three countries recommended vaccination of educational staff (table 12).

Table 12. Other occupations recommended seasonal influenza vaccine in EU/EEA countriesin 2012-13 influenza season. National seasonal influenza vaccination survey, March 2014(n=33)

Profession Recommendeda No recommendationb

Police & Firemen BG,EE,IS,IT,MT,PL,ES

DE,BE,HR,FR,GR,HU,IE,NL,NO,SI,UK-ENG, UK-WL,FI,CY,LI,SK

Military BG,EE,FI,DE,GR,IT,MT,PL,SK,SI,ES

BE,HR,CY,FR,HU,IS,IE,LI,NL,NO,UK-ENG,UK-WL

Border/Immigration control/ customs EE,IS,IT,MT,PL BE,BG,HR,FR,DE,GR,HU,IE,NL,NO,SI,ES,UK-ENG,UK-WL,FI,CY,LI,SK

Veterinary EE,IE,IS,IT,MT,SI,CY

BE,BG,HR,FR,DE,GR,HU,NL,NO,PL,ES,UK-ENG,UK-WL,FI,LI,SK

Public transport (e.g. ground, rail, air,marine) (if specific recommendations forparticular transport workers, pleasespecify)

EE,PL,BGc,FRd BE,HR,DE,GR,HU,IS,IE,IT,MT,NL,NO,SI,ES,UK-ENG,UK-WL,FI,CY,LI,SK

Educational staff - e.g. primary/secondaryschools, preschool centres, kindergartens,crèches - please specify if for all or forsome educational staff.)

EE,PLe,LIf BE,BG,HR,FR,DE,GR,HU,IS,IE,IT,MT,NL,NO,SI,ES,UK-ENG,UK-WL,FI,CY,SK

Community services (energy, electricity,water)

EE,PL BE,BG,HR,FR,DE,GR,HU,IS,IE,IT,MT,NL,NO,SI,ES,UK-ENG,UK-WL,FI,CY,LI,SK

Postal service EE,PL BE,BG,HR,FR,DE,GR,HU,IS,IE,IT,MT,NL,NO,SI,ES,UK-ENG, UK-WL,FI,CY,LI,SK

Poultry industry workers BE,EE,DE,GR,HU,IS,IE,IT,SI,CY,LI

BG,HR,FR,MT,NL,NO,PL,ES,UK-ENG,UK-WL,FI,SK

Swine industry workers BE,EE,IS,IE,IT,CY,LI BG,HR,FR,DE,GR,HU,MT,NL,NO,PL,SI,ES,UK-ENG,UK-WL,FI,SK

Families raising swine, poultry or geese EE,IS,IE,NO,LI BE,BG,HR,FR,DE,GR,HU,IT,MT,NL,PL,SI,ES,

29

UK-ENG,UK-WL,FI,CY,SKSocial care workers BG,EE,HU,MT,PL,ES

,UK-ENG,UK-WL,FIBE,HR,FR,DE,GR,IS,IE,IT,NL,NO,SI,CY,LI,SK

Laboratory workers working in otherlaboratories (not medical/public healthlaboratories, but who may work withavian influenza viruses in theenvironmental/ academic sector )

HR,EE,DE,GR, IE,IS,IT,MT,NL,SI,LI,SK

BE,BG,CY,FI,FR,HU,NO,PL,ES,UK-ENG,UK-WL

Wildlife environmentalists (workers whowork with birds directly e.g. bird ringing)

EE,DE,IE,LI,SK BE,BG,HR,FR,GR,HU,IS,IT,MT,NL,NO,PL,SI,ES,UK-ENG,UK-WL,FI,CY

Other IEg, NOh,UK-WLi,LIj -None of above CZ,DK,LV,LT,LU,RO,SE,PT,UK-NI,UK-SCa “No recommendation” defined here, and in the following questions, as an absence of a specific writtenrecommendation in the official policy document regarding vaccination for this group.b “Recommended” is defined here, and in the following questions, as the existence of a specific writtenrecommendation in the official policy document that this population group should receive seasonal influenzavaccine.c Recommended for some.d Crew members of airlines and cruises lines, tourist guides.e All- teachers and administrative workers.f Kindergarten and crèches.g Abattoir and zoo workers;h Others in regular contact with live swine.i Members of voluntary organisations providing planned emergency first aid.j Whoever wishes to minimize their risk of influenza.

In the 2012-13 season there were no recommendation changes relating to otheroccupational groups in any of the 33 countries (BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT) in comparison toinfluenza season 2011-12.

Payment scheme and funding mechanism for other occupational groups

Data relating to payment schemes and funding mechanisms for seasonal influenza vaccinewith regard to recommendations to HCWs, by country, are presented in tables 13 and 13a.

Table 13. Payment scheme and funding mechanism for other occupations (professions) inEU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccinationsurvey, March 2014 (n=23)

Payment scheme For vaccine itself For vaccine administrationEmployer NL,NO,SI,UK-WL,LI,SK,FR LI,NL,NO,SI,SK,UK-WL,FRNational health service HR,IS,IT,MT,UK-ENG,FI IT,MT,UK-ENGEmployer;National insurance scheme;Private insurance

DE,HU DE,GR,HU

30

Out of pocket;Employer

BG,EE BG,EE

Regional health service ES ES,FINational health service;Out of pocket;Employer

IE


- IE

National insurance scheme - HRNational insurance scheme;National health service;

GR

Out of pocket - ISNational insurance scheme;Out of pocket;Employer

BE BE


PL -


- PL

National health service;Private insurance;Out of pocket

CY CY

* Out of pocket means not reimbursed, paid by vaccinee.CZ,DK,LV,LT,LU,RO,SE,UK-NI,UK-SC,PT- Not applicable.

Table 13a. Co-payment for vaccine and administration of vaccine (vaccination) for otheroccupations for influenza vaccination in EU/EEA countries in 2012-13 influenza season.National seasonal influenza vaccination survey, March 2014 (n=20)


There is no co-payment DE,BG,HR,EE,FI,FR,GR,IS,IE,IT,LI,MT,NL,NO,PL,SK,SI,ES,UK-ENG,UK-WL

Co-payment exista BE, CYCo-payment for administration

There is no co-payment DE,BG,HR,EE,FI,FR,IS,IE,IT,LI,MT,NL,NO,PL,SK,SI,ES,UK-ENG,UK-WL

Co-payment existb BE,CYa, b BE-Partly refunded.a, b CY- There is a co-payment in cases they are eligible to "free" health care by the public. The others pay out ofpocket or by private insurances.

Comment for issues with reimbursement of cost of vaccine, or its administration, that may influencevaccination coverage:EE- Full cost of vaccine and vaccination paid by vaccinee. For some occupational workers vaccines andvaccinations are being paid by employer.

31

IE- For work purposes, if recommended the flu vaccine for work this should be paid by employer. For privateindividuals with small flocks (farmers, families) they would have to pay costs for vaccine and administrationthemselves (out-of-pocket) should be paid by employer.PL- Local government reimbursement of cost of vaccine only for special age group -mostly for elderly.UK-WL - There may well be issues for this group, although we have no data available. The answer is 'probably'.

Population groups in closed communities

Twenty-nine of the 33 survey participating countries recommended vaccination of residentsof long-term care facilities; vaccine for prisoners was recommended in three countries;vaccine for children in day care centers was recommended in five countries (table 14).

Table 14. Other population groups in closed communities recommended seasonal influenzavaccine in EU/EEA countries in 2012-13 influenza season. National seasonal influenzavaccination survey, March 2014 (n=33)

Population group Recommendeda No recommendationb

Prisoners EE,MT,PL BE,BG,HR,CZ,DK,FR,DE,GR,HUIS,IE,IT,LV,LT,LU,NL,NO,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT

Children in day care centres,boarding schools etc.

BG,EE,GR,MT,PL BE,HR,CZ,DK,FR,DE,HU,IS,IE,IT,LV,LT,LU,NL,NO,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT

Residents of long term carefacilities

BE,BG,HR,CZ,EE,FR,DE,GR, LTc ,HU,IS,IE,IT,LU,MT,NO,PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT

DK,LV, NLd,SE

Other, Please specify IEe,LUf -a “No recommendation” is defined here, and in the following questions, as an absence of a specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.b”Recommended” is defined here, and in the following questions, as the existence of a specific writtenrecommendation in the official policy document that this population group should receive seasonal influenzavaccine .c Recommended: people, which live in social or nurse institutions.d Persons with a mental handicap living in residential homes.e Children with any condition that can compromise respiratory function (e.g. spinal cord injury, seizuredisorder, or other neuromuscular disorder) especially those attending special schools/ day centre.f All residents of close communities.

In the 2012-13 season there were no recommendation changes with regard to populationgroups in closed communities in any of the 33 countries(BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT) in comparison to influenza season 2011-12.

Payment scheme and funding mechanism for population groups in closed communities

32

Data on payment schemes and funding mechanisms for seasonal influenza vaccine withregard population groups in closed communities, by country, are presented in tables 15 and15a.

Table 15. Payment scheme and funding mechanism for population groups in closedcommunities influenza vaccination in EU/EEA countries in 2012-13 influenza season.National seasonal influenza vaccination survey, March 2014 (n=29)

Payment scheme For vaccine itself For vaccine administrationNational health service HR,IS,IE,IT,LT,MT,

UK-ENG,UK-NI,UK-SC,UK-WL,FI,PT

IT,LT,MT,UK-ENG,UK-NI,UK-SC, UK-WL,PT

National insurance scheme FR,GR,SI,SK HR,CZ,GR,LU,SKOut of pocketa EE,LU EE,SIRegional health service ES ES,FIEmployer - ISNational health service;Out of pocket

- IE

National insurance scheme;Regional health service;Out of pocket

BE BE


DE DE

Goverment (Public HealthService)

HU -

No extra pay of administrationof flu vaccine

- HU

Health care facility NO NOMinistry of Health;Public Sector

RO RO

See above - such residents areelderly or with chronicconditions

CZ -


- PL,FR


PL -

Out of pocket;Ministry of Health

BG BG

National health service;Private insurance;Out of pocket

CY CY

Private insurance LI LIaOut of pocket means not reimbursed, paid by vaccinee.DK,LV,NL,SE -Not applicable.

Table 15a. Co-payment for vaccine and administration of vaccine (vaccination) forpopulation groups in closed communities influenza vaccination in EU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccination survey, March 2014 (n=28)

33


There is no co-payment DE,BG,HR,EE,FR,GR,HU,IS,IE,IT,LT,MT,NO,PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI,SK,PT,NO

Co-payment exista BE,CZ,LU,CY,LICo-payment for administration

There is no co-payment DE,BG,HR,CZ,EE, GR,HU,IS,IE,IT,LT,MT,NO,PL,RO,SIES,UK-ENG,UK-NI,UK-SC,UK-WL,FI,SK,PT,NO

Co-payment existb BE,LU,CY,LI, FRa, b BE- Partly refunded.a, b CY- There is a co-payment co-payment in cases they are eligible to "free" health care by the public. Theothers pay out of pocket or by private insurances.a, b LI- 10% of the cost.a LU- out of pocket.a CZ- only cheapest vaccine is covered from insurance for people with chronic conditions. For other vaccine,you have to pay the difference.b LU- 10% of the doctor's visit price.b FR- 35% of the vaccine administration cost is paid by the patient which is refunded if the patient has a privateinsurance (most of the time). Those with a chronic disease are totally refunded by the national insurance.

Comment for issues with reimbursement of cost of vaccine, or its administration, that may influencevaccination coverage:EE- Full cost of vaccine and vaccination paid by vaccinee.IE- Most living or working in closed communities would be vaccinated free of charge, in theory some may haveto pay if they are not eligible (in which case this would negatively impact on uptake).

Household contacts or care takers

Household contacts of babies <6 months of age were recommended vaccine in sevencountries; contacts of those with clinical risk were recommended vaccine in 20 countries;contacts of immunosuppressed individuals were recommended vaccine in 22 countries(table 16).

Table 16. Household contacts or caretakers recommended seasonal influenza vaccine inEU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccinationsurvey, March 2014 (n=33)

34

Householdcontact/Carer of:

Recommendeda No recommendationb

Infants <6 months of age BE,EE,GR,LU,PL,FI,LI BG,HR,CY,CZ,DK,FR,DE,HU,IS,IE,IT,LV,LT,MT,NL,NO,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,SK,PT

Immunosuppressedindividuals

BE,BG,HR,DK,EE,CY,DEGR,IS,IE,IT,LU,NL,PL,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,LI

CZ,FR,HU,LV,LT,MT,NO,RO,SI,SK,PT

Persons with clinical riskindication

BE,BG,HR,CY,CZ,EE,FI,DE,GR,IS,IE,IT,LI,LU,NL,PL,RO,ES,UK-NI,UK-WL

DK,FR,HU,LV,LT,MT,NO,PT,SK,SI,SE,UK-ENG,UK-SC

Adults (≥65) BG,EE,GR,IS,IE,LU,PL,UK-NI,UK-WL,FI,LI

BE,HR,CY,CZ,DK,FR,DE,HU,IT,LV,LT,MT,NL,NO,RO,SI,ES,SE,UK-ENG,UK-SC,SK,PT

Other FRc,IEd,LUe,UK-SCf,UK-WLg,PTc

,NOh

-

a “No recommendation” is defined here, and in the following questions, as an absence of a specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.b”Recommended” is defined here, and in the following questions, as the existence of a specific writtenrecommendation in the official policy document that this population group should receive seasonal influenzavaccine.c Infants <6 months of age with clinical risk indication.d Household contacts of at-risk persons and out-of-home care givers to at-risk person (at risk groups are manyand are outlined in national guidance).e Care takers of infant and toddlers <2 years of age.f Unpaid carers.g Those who are in receipt of a carer’s allowance, or those who are the carer of an elderly or disabled personwhose welfare may be at risk if the carer falls ill.h Household contacts of severely immunosuppressed individuals.

In the 2012-13 season there were no changes in recommendations with regard tohousehold contacts or care takers recommended seasonal influenza vaccine in any of 33countries (BE,BG,HR,CZ,DK,EE,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,FI,CY,LI,SK,PT) in comparison to influenza season 2011-12.

Payment scheme and funding mechanism for household contacts or care takers

Payment scheme and funding mechanism for seasonal influenza vaccine with regardpopulation groups in closed communities by country presented in tables 17 and 17a.

Table 17. Payment scheme and funding mechanism for household contacts or care takers inEU/EEA countries in 2012-13 influenza season. National seasonal influenza vaccinationsurvey, March 2014 (n=26)

35

Payment scheme For vaccine itself For vaccine administrationNational health service HR,DK,FI,IS,IE,IT,UK-ENG,

UK-NI,UK-SC,UK-WLDK,IT,UK-ENG,UK-NI,UK-SC,UK-WL

Out of pocket EE, BG,NL, CZ BG,EE,IS,NLNational insurance scheme; FR,GR HR,GRNational insurance scheme;Out of pocket

BE BE


DE CZ,DE

Ministry of Health, PublicSector

RO RO

Out of pocket;Employer

LU -


PL -

National insurance scheme;Private insurance;Employer

- PL

Regional health service; ES ES,FIRegional health service;Out of pocket;Varies with regions: In someregions, the vaccinee wascharged a symbolic amount(approximately 10€) forvaccine & vaccination

SE SE


- IE

National insurance scheme;Employer

- LU

Private insurance; LI LI37% reimbursement; vaccinefree for ≥ 65 years and otherrisk groups

PT -

National health service;paid if administered inpharmacies

- PT

National health service;Private insurance;Out of pocket;

CY CY


FR

* Out of pocket means not reimbursed, paid by vaccinee.HU,LV,LT,MT,NO,SI,SK- Not applicable.

36

Table 17a. Co-payment for vaccine and administration of vaccine (vaccination) forpopulation groups in household contacts or care takers in EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=26)


There is no co-payment DE,BG,HR,DK,EE,FR,GR,IS,IE,IT,NL,PL,RO,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI

Co-payment exista BE,CY,CZ,LU,SE,LI,PTCo-payment for administration

There is no co-payment DE,BG,HR,DK,EE, GR,IS,IE,IT,NL,PL,RO,ES,UK-ENG,UK-NI,UK-SC,UK-WL,FI,PT

Co-payment existb BE,CY,LU,SE,LI,FRa,b BE -Partly refunded in some groups.a,b CY-There is a co-payment in cases they are eligible to "free" health care by the public. The others pay out ofpocket or by private insurances.a CZ-You have to pay 100%.a,b LI-10% of the cost.a LU-Out of pocket for private contacts or if employer doesn't provide the vaccine.a PT-37% reimbursment NHSa,b SE-In some regions, the vaccinee was charged a symbolic amount (approximately 10€) for vaccine &vaccination.b LU-10% of the doctor's visit price.b FR-35% of the vaccine administration cost is paid by the patient which are refunded if the patient has aprivate insurance (most of the time).HU,LV,LT,MT,NO,SI,SK- Not applicable.

Comment for issues with reimbursement of cost of vaccine, or its administration, that may influencevaccination coverage:EE-Full cost of vaccine and vaccination paid by vaccinee.IE-Household contacts, if they do not have medical card would have to pay, employee care givers would nothave to pay (covered by employer).

Recommendation for travellers

Of the 33 survey participating countries eight indicated having influenza vaccinerecommendations for travellers (EE,DE,IE,LT,MT,SI,UK-SC,FI). In FI influenza vaccine isrecommended for those travellers if they belong to medical risk groups. In UK-SC season/circumstance dependent, the details are presented in the following document:http://www.fitfortravel.nhs.uk/advice/disease-prevention-advice/influenza.aspx . In IE all travellersare considered at some risk of influenza especially as they often travel in crowdedconditions and visit very crowded locations; at risk travellers going to another hemisphereduring influenza season are recommended to arrange to have influenza vaccine as soon aspossible after arriving at their destination. In DE the recommendation are restricted anddepend on the destination, risk factors, and available vaccine. In SI and LT influenza vaccineis recommended for all travelling from November to February in the northern hemisphereand from April to September in the southern hemisphere. In EE and MT vaccine isrecommended to all travellers and there are no restrictions to certain regions, countries ofspecific population groups.

37

Overall comments on groups recommended for seasonal influenza vaccination and needs for furtherscientific guidance from ECDC:HR- Scientific guidance is OK and just has to be updated periodically.DK-We would like more evidence-based scientific guidance recommendation of influenza vaccination topregnant and postpartum women. We also hope that ECDC will follow-up with scientific guidance onvaccination with LAIV to children.PL- because recommendation exist, we need update scientific guidance support.SE- More information regarding vaccination of children with live-attenuated vaccines would support our work.

Section II: VACCINATION COVERAGE DATA (SEASON 2012-13)

Overall, for the season 2012-13,29 countries provided vaccination coverage(VC) calculatedfor entire population or different age and population groups, using administrative methods:BG,HR,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LV,LT,LU,MT,NL,NO,PL,PT,RO,SK,SI,ES,SE,UK-ENG,UK-WL,UK-NI,UK-SC. Four countries (BE,CY,CZ,LI) did not provide VC forany population group. Eight countries provided VC data for entire population(BG,SI,PL,LT,NO,HU,SK,MT), ranging from 2.7% in BG to 19% in MT.

Influenza VC among older population (≥55; ≥ 60, ≥ 65 years of age) was measured in 26countries (MT,IS,DE,NL,HR,EE,DK,FR,HU,FI,IE,IT,LV,LT,LU,NO,SI,ES,SE,PL,RO,UK-ENG,UK-NI,UK-SC,UK-WL,PT). The VC among those > 65 varied from 1% in EE to 77.4% in UK-SC;median was 45%.

VC for clinical risk groups was reported by nine countries and ranged from 28% in PT to80.2% in UK-NI; median was 50%. NO reported a combined vaccination coverage of 44.5%for both clinical risk groups and those aged ≥65 years.

Estimates of coverage for residents of long stay care facilities were provided by threecountries (SK,PT,IE) and VC reported was 71.1%, 89%, and 73% respectively.

Ten countries (HU,IE,IT,LT,RO,SI,UK-ENG,UK-NI,UK-SC,UK-WL) provided VC data forpregnant women, which varied from 0.2% in LT to 64.6% in UK-NI; median was 16%.

Thirteen countries (HR,HU,IE,PL,LT,RO,ES,UK-ENG,UK-NI,UK-SC,UK-WL,PT,GR) were able toprovide VC data for HCWs with a wide range reported, from 9.5% in PL to 45.6% in UK-ENG;median was 28%. Details are presented in table 18.

Table 18. Reported Seasonal influenza vaccination coverage, by method of monitoring, forentire population or targeted population groups among EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=29)

Country Measured/estimated vaccination coverage (%)Administrative

methodSurvey

methodCombination ofadministrative

and surveymethod

Immunisationregistry

Entire populationBG 2.67 - - -

38

SI 4.4 - - -PL 5.3 - - -LT 6.95 - - -NO 10.4 - - -HU 9.7 - - -SK 4.6 - - -MT 19

Children and adolescents≥6months-18 years

FI - - - 4LV 0.02 - - -SI 0.4 - - -

≥6months-15 yearsSK 1.6 - - -

≥6months - 24 monthsLV 0.12 - - -

12 months -36 monthsFI - - - 15

<15 yearsPT - 9 - -

AdultsOverall adults ≥18years

IE - 21 - -NL 19.8 - - -NO - 15.4 - -SI 5.1 - - -PT - 16 - -SKa 4.8 - - -

Healthy adults ≥18yearsNO - 10 - -

Adults ≥18years with clinical condition/risk

NO - 37.1 - -PT - 28 - -

Adults ≥50 yearsEE 1 - - -

Overall adults ≥55 yearsMT 52 - - -

Overall adults ≥60 yearsIS 44.7 - - 44.7NL 67.8 - - -DE 37.4 - - -

Healthy adults ≥60 yearsIS 44.7 - - 44.7NL 51.8 - - -

39

Adult ≥60 years of age with clinical indication/riskNL 76.5 - - -

Overall adults ≥65 yearsHR 30 - - -EE 1 - - -DK - - - 46FR 53.1 - - -HU 30.9 - - -FI - - - 38IE 56.9 60 - -IT 54.2 - - -LV 1.8 - - -LT 19.2 - - -LU 43.3 - - -NO - 36.2 - -SI 16.8 - - -ES 57 - - -SE - - 44 -PL 7.4 - - -RO 53 - - -UK-ENG 73.4 - - -UK-NI 75 - - -UK-SC 77.4 - - -UK-WL 67.7 - - -PT - 45 55 -

Healthy adults ≥65 yearsNO - 27.8 - -

Adults ≥65 years with clinical condition/riskNO - 53.5 - -

All clinical risk groups and ≥ 65 years togetherNO 44.5 - - -

Children, adolescents and adults with clinical risk ≥6months-64 yearsFR 39.1 - - -NL 52.1 - - -UK-ENG 51.3 - - -UK-NI 80.2 - - -UK-SC 59.2 - - -UK-WL 49.7 - - -

Children, adolescents and adults with clinical risk other age groups

IEb -

28.4(age ≥18-64

years) - -NLc 72.1 - - -PT 28 (≥6

months of

40

age)

Overall pregnant womenHU 3.3 - - -IE - 27.8 - -IT 0.36 - - -LT 0.2 - - -RO 4.2 - - -SI 1.4 - - -UK-ENG 40.3 - - -UK-NI 64.6 - - -UK-SC 54.1 - - -UK-WL 43.6 - - -

Healthy pregnant womenUK-ENG 38.8 - - -UK-SC 52.9 - - -UK-WL 52.1 - - -

Pregnant women with additional clinical riskUK-ENG 59 - - -UK-SC 68.7 - - -UK-WL 59.6 - - -

Overall HCWsHR 19 - - -HU 29.2 - - -IE - 29.5 - -PL 9.5 - - -LT 36.6 - - -RO 42 - - -ES 22.9 - - -UK-ENG 45.6 - - -UK-NI 14.8 - - -UK-SC 33.7 - - -UK-WL 35.5 - - -PT 28 - - -

Outpatient healthcare settingsGR 19 - - -UK-ENG 49.6 - - -PT 45 - - -

Inpatient health care settingsGR 11.5 - - -IE 17.4 - - -UK-ENG 45.3 - - -UK-NI 20.4 - - -PT 24 - - -

Long term health care settings

41

IE 15 - - -PT 27 - - -

Military/Armed forcesFI 90 - - -

Residents of long term care facilitiesIE 73 - - -PT 89 - - -SK 71.1 - - -

Household contacts or care takersUK-WL 53.2 - - -a In SK VC of total population for the age groups 0-15 years, 16-58 years and ≥59 and more years is monitored; for thisquestionnaire we put the two latter age groups together.bNational telephone Survey 2012-2013 conducted in September 2013.cNL- Vaccination coverage by age groups – Adults (any age group ≥ 18) with clinical condition/risk.

Comments on VC for clinical risk groups:NL calculation of VC for clinical risk groups -Coverage data is not available, but coverage is available fromgroups with different conditions/risks. Coverage % of 72,1% is not a statistic correct aggregated %: patientswith abnormalities and functional disorders of the airways and lungs: 66,4; patients with a chronic heartdisorder: 74,5%; patients with diabetes mellitus: 76,3%;patients with a chronic kidney disease: 79,5% ;personsinfected with HIV: 66,1; persons with a reduced resistance to infection (e.g. because of (functional) asplenia,auto-immune disease, liver cirrhosis, chemotherapy or immunosuppressive medication): 70,8%.

Comments on VC for adults:HR-Number of vaccinated available (98200), but denominator unknown.DK-Only information on absolute numbers.IE-National Telephone Survey 2012-2013 conducted in August-September 2013.LI-The government does not survey vaccination coverage in adults.PL-coverage is possible to estimate according the following age groups:0-4, 5-14, 15-64 and >65.UK-WL - Public Health Wales monitor General Practice influenza immunisation uptake rates throughout theseasonal campaign and produce end of season influenza immunisation coverage statistics at national, HealthBoard and Local Authority level. Immunisation statistics published are not a measure of all those who havebeen immunised during the course of the immunisation campaign, but represent a snapshot in coverage inthose living and registered with Welsh General Practices at the end of the immunisation campaign. Data oninfluenza immunisation for the 2012/13 campaign were collected directly from General Practice computerrecords using centrally provided software, which interrogates General Practice systems using specified Read-codes and automatically relays the relevant anonymous aggregate data to a central database.Overall comments on VC:IE-we did a national telephone survey in August-September 2013 and we also surveyed hospitals andresidential facilities to obtain administrative data. Difficult to obtain data as registries are not available andvaccination of staff not closely monitored.LT-In Lithuania general population flu vaccination coverage in 2012-2013 flu season was 6,95%. Population2944459 people.MT-A total of 75,200 doses were administered to eligible groups and the general population through NationalImmunisation Service. An unspecified number of vaccines also taken through private sector. Total countrypopulation 400,00-19%.PL-coverage is estimated according to the age groups (4 groups acc. WHO) in population and for HCWs only.LU-coverage for 65+ populations might be overestimated as the numerator concerns all patients that had areimbursement for at least on vaccine dose during the season, resident and non-resident social securityaffiliated persons. As our transborder working population is important, this concerns also an importantnumber of retired former transborder workers residing in a neighbour country but still socially insured inLuxembourg and in their residing country. Nevertheless it is estimated that their use of the Luxemburgishsocial insurance system for flu vaccination is very limited due to a free of charge flu vaccination policy for the65+ population in the neighbouring countries.

42

Section III: METHODS TO MONITOR VACCINATION COVERAGE, SAFETY ANDEFFECTIVENESS

Method/s and mechanism/s used to measure vaccination coverage

Of 33 responding countries 27 monitor seasonal influenza vaccination coverage usingadministrative method only; four countries use a combination of administrative and surveymethods and the remaining two use only survey methodology to monitor influenzavaccination coverage (table 19).

Table 19. Mechanism used to monitor seasonal influenza vaccination coverage in EU/EEAcountries in 2012-13 influenza season. National seasonal influenza vaccination survey,March 2014 (n=33)

Countries TotalAdministrative method only DE,BG,HR,CY,CZ,DK,EE,FI,FR,GR,HU,IS,IT,LV,

LT,LU,MT,NL,PL,RO,SK,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL

27

Combination of administrativeand survey methods

IE,NO,SE,PT 4

Survey method only BE,LI 2Frequency: every 4 years BE 1Frequencya LI 1

a Not specified.

There have been no changes in the methods for monitoring influenza vaccination coveragein comparison to those used in the influenza season 2011-12 in 31 countries (BE,BG,HR,CY,CZ,DK,EE,FI,FR,GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,PL,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL). Two countries, DE and PT, reported changes to vaccination coveragemonitoring in their countries. In DE- usually there is annual survey to assess influenzavaccination coverage in the older population and at-risk-groups; due to technical reasons nosuch survey in 2012-13 was conducted; however, administrative data were used to estimatecoverage in persons aged >60 years. In PT, “weekly number of vaccines administered withinNHS is available now.”

The methods used for monitoring vaccination coverage by population groups recommendedfor vaccination and details relating to specific groups are provided in tables 20 and 20a. Theinformation relating to status of development of immunisation registries to documentinfluenza vaccination in the countries, and when these are expected to be available for useis summarised in table 20b.

Table 20. Methods (administrative or survey) used to monitor vaccination coverage bypopulation groups recommended for seasonal influenza vaccine in EU/EEA countries in2012-13 influenza season. National seasonal influenza vaccination survey, March 2014(n=33)Population groups Administrative Survey Both No

monitoringNot applicable

Entire population SI,DE,NO,SK EE BE,BG,HR,CY,CZ,DK,FI ,FR, GR,HU,IS,

43

IE,IT,LV,LI,LT,LU,MT,NL,PL,RO,ES,SE,PT,UK-ENG,UK-NI,UK-SC,UK-WL

Children andadolescents

FI,LV,SKa,SI EE,MT BG,BE,HR,CY,CZ,DK,FR,DE,GR,HU,IS,IE,IT,LI,LU,LT,NL,NO,PL,RO,ES,SE,PT,UK-ENG,UK-NI,UK-SC,UK-WL

Adults: aged 18 - <65 years old

NL,SKa,DE BE,IE EE,IS,MT,PT BG,HR,CY,CZ,DK,FI,FR,HU,IT,LV,LI,LT,LU,NO,PL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,GR

Adults: aged >65years old

HR,DK,EE,FI,FR,HU,LV,LU,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL,DE,SKa,LT,IT

NO IE,PT,SE

BG,CZ,LI,CY,GR(>60)

BE,DE,IS,MT,NL,PL,RO

Individuals withmedical/riskconditions (clinicalrisk groups)

HR,FR,IT,LV,NL,SI,UK-NG,UK-NI,UK-SC,UK-WL

BE, IE,NO, PT

- BG,CY,CZ,DK,EE,FI,GR,HU,IS,LI,LT,LU,MT,PL,RO,SK,ES,SE, DE

-

Pregnant women UK-ENG,UK-SC,HU,LT

IE - DK,FR,SE,DE,GR,NO,ES

BG,BE,HR,CY,CZ,EE,FI, IS,IT,LV,LI,LU,MT,NL,PL,PT,RO,SI, UK-NI,,UK-WL,SK

Health careworkers

UK-SC,HU,GR,SK,UK-ENG,LT

- IE BG,SE, NO BE, HR,CY,CZ,EE,FI,FR,DE, DK,IS,IT,LV,LI,LU,MT,NL,PL,PT,RO,SI,ES,UK-NI, UK-WL

Essential publicsector workers

IT - - BE,BG,CY,HR,EE,FI,DE,GR,HU,IS,IE,LI,MT,NL,NO,PL,SK,SI,ES,

CZ,DK,LV,LT,LU,PT,RO,SE,UK-NI,UK-SC,FR

44

UK-ENG,UK-WL

Prisoners - - - EE,MT BE,BG,CY,HR,CZ,DK,FI,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,NL,NO,PL,PT,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL

Residents of longterm careinstitutions

IT,LI,PT,SK - IE BE,BG,HR,CY,CZ,EE,FI,FR,DE,GR,HU,IS,LU,MT,NO,PL,RO,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL

DK,LV,LT,NL,SE

Educationalinstitutions

- - - EE,MT,PL BG,BE,HR,CY,CZ,DK,FI,FR,DE,HU,IS,IE,IT,LV,LI,LT,LU,NL,NO,PT,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL, GR

Household contact/Carer of:Infants <6 monthsof age

- - - BE,EE,FI,GR,LI,LU

BG,HR,CY,CZ,DK,FR,DE,HU,IS,IE,IT,LV,LT,MT,NL,NO,PL,PT,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL

Immunosuppressed individuals

IT,UK-WL,UK-SC

- - BE,BG,CY,HR,DK,EE,FI,DE,GR,IS,IE,LI,LU,NL,PL,ES,SE,UK-ENG,UK-NI

CZ,FR,HU,LV,LT,MT,NO,PT,RO,SK,SI

Persons withclinical riskindication

IT,UK-WL - - BE,BG,HR,CY,CZ,EE,FI,DE,GR,IS, IE,LI,LU,NL,PL,RO,ES,UK-NI

DK,FR,HU,LV,LT,MT,NO,PT,SK,SI,SE,UK-ENG,UK-SC

Adults (>65) UK-WL,ES - - BG,EE,FI,GR,

BE,HR,CY,CZ,DK,FR,DE,HU,IT,LV,LT,MT,

45

IS,IE,LI,LU,UK-NI

NL,NO,RO,PL,PT,SK,SI,SE,UK-ENG,UK-SC

Other, pleasespecify

UK-SC,UK-WL

- - BE,EE,FR,IE,LI,LU,PT,NO

BG,HR,CY,CZ,DK,FI,DE,GR,HU,IS,IT,LV,LT,MT,NL,PL,RO,SK,SI,ES,SE,UK-ENG,UK-NI

a The vaccination coverage is monitored for officially and also not officially recommended age groups (overallentire population, overall children 0 – 15 years, overall adolescents and adults 16 – 58 years and overall 59years and older).

Table 20a. Details on administrative methods used to monitor vaccination coverage bypopulation groups recommended for seasonal influenza vaccination in EU/EEA countries in2012-13 influenza season. National seasonal influenza vaccination survey, March 2014(n=33)

Populationgroups

Medical records Immunisationregistry a

Notapplicable

Blank

Manual

Electronic Manual Electronic

Entirepopulation

SI DE,SK EE,FR BE,BG,HR,CY,CZ,DK,FI, GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,PL,PT,RO,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL

Childrenandadolescents

LV,SI SK FI BG,EE,LT,MT,PL,FR

BE,HR,CY,CZ,DK,DE,GR,HU,IS,IE,IT,LI,LU,NL,NO,RO,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

46

Adults aged18 - < 65years old

NL,SK,DE BE,EE,GR,IS,IE,MT,PL,FR

BG,HR,CY,CZ,DK,FI,HU,IT,LV,LI,LT,LU,NO,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

Adults aged>65 yearsold

HR,HU,LV,SI,UK-NI

ESb,SEb,EE,IE,DE,LUc,SK,UK-ENG,UK-SC,UK-WL

ESb,SEb,DK,FI,PT

BG,CZ,LI,NO BE,CY,GR,IS,IT,LT,MT,NL,PL,RO, FR,

Individualswithmedical/riskconditions(clinical riskgroups)

HR,LV,SI,UK-NI

NL,UK-ENG,UK-SC,UK-WL

IT BE,BG,CZ,DK,EE,FI,DE,GR,HU,IS,IE,LI,LT,LU,MT,NO,PL,RO,SK,ES,SE

CY, FR,PT

Pregnantwomen

HU UK-SC, UK-ENG

BG, SK,SE BE,HR,CY,CZ,DK,EE,FI,FR,DE,GR,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,PL,RO,SI,ES, ,UK-NI, ,UK-WL,PT

Health careworkers

HU,UK-ENG

SE BE,BG,HR,CY,CZ, DKEE,FI,FR,DE,GR,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,PL,RO,SK,SI,ES, ,UK-NI,UK-SC,UK-WL,PT

Essentialpublicsectorworkers

IT BE,BG,HR,EE,FI,FR,DE,GR,HU,IS,IE,LI,MT,NL,NO,PL,SK,SI,ES,UK-ENG,UK-WL

CY,CZ,DK,LV,LT,LU,RO,SE,UK-NI,UK-SC,PT

Prisoners EE,MT,PL,FR BE,BG,HR,CY,CZ,DK,FI,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

Residents oflong termcare

IE,LI,SK

IT,PT BE,BG,HR,CZ,EE,FI,FR,DE,GR,HU,IS,

CY,DK,LV,LT,NL,SE

47

institutions LU,MT,NO,PL,RO,SIES,UK-ENG,UK-NI,UK-SC,UK-WL

Educationalinstitutions

BG,EE,GR,MT,PL,FR

CY,BE,HR,CZ,DK,FI,DE,HU,IS,IE,IT,LV,LI,LT,LU,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

Household contact/Carer of:Infants <6months ofage

BE,EE,FI,GR,LI,LU,PL,FR

BG,HR,CY,CZ,DK,DE,HU,IS,IEIT,LV,LT,MT,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

Immunosuppressedindividuals

UK-WL,UK-SC

IT BE,BG,HR,DK,EE,FI,FR,DE,GR,IS,IE,LI,LU,NL,PL,ES,SE,UK-ENG,UK-NI,

CY,CZ,HU,LV,LT,MT,NO,RO,SK,SI,PT

Personswith clinicalriskindication

UK-WL IT BE,BG,HR,CZ,EE,FI,FR,DE,GR,IS,IE,LI,LU,NL,PL,RO,ES,UK-NI

CY,DK,HU,LV,LT,CY,MT,NO,SK,SI,SE,UK-ENG,UK-SC,PT

Adults (>65) UK-WL BG,EE,FI,FR,GR,IS,IE,LI,LU,PL,UK-NI

BE,HR,CY,CZ,DK,DE,HU,IT,LV,LT,MT,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-SC,PT

b Both medical records and immunization registries. Medical records: Electronic; Immunisation registries:Electronic.cCoverage assessed on the basis of medico-administrative reimbursement data.

Table 20b. Development of electronic immunisation registries and their availability todocument exposure of influenza vaccines. National seasonal influenza vaccination survey,March 2014 (n=8)

Status ofimmunisation

registry

Countries Expected availability for useto document exposure to influenza vaccines

Immunisationregistry is underdevelopment

HR,PL 2017

EEElectronic immunization record form is created since 2011 inthe frame of e-health system. It is available for use now.

48

FI

It is being developed, almost real time covering over 50% ofpopulation right now, entire country hopefully by the end ofthe year

IT Information not availableLV Not specifiedSK This is the responsibility of National Health Information

Center (budgetary organization of MoH)SI 2015

NO-In Norway an electronic immunisation registry is established. Influenza vaccination has been notifiable tothe Norwegian immunisation registry since 2011. However the reporting to the registry is incomplete. Onlyabout 40 % of the doses distributed is reported to the immunisation registry.

Ten countries estimated that more that 90% of all vaccination sites report vaccinationcoverage; 18 countries do not know the proportion of vaccination sites reportingvaccination coverage (table 21).

Table 21. Proportion on vaccination sites reporting vaccination coverage. National seasonalinfluenza vaccination survey, March 2014 (n=33)

Countries TotalLess than 50% of all sites BE,CY,LI 3Between 50 and 70% of all sites - 0Between 70 and 90% of all sites FI,SI 2

More than 90% of all sites HR,EE,HU,IS,IT,UK-ENG,UK-NI,UK-SC,UK-WL,PT 10

Not known BG,CZ,DK,FR,DE,GR,IE,LV,LT,LU,MT,NL,NO,PL,RO,SK,ES,SE

18

Of 27 countries that reported monitoring by administrative method only, in eight of thesecountries there is no time lag between vaccination and reporting to a medical card orimmunisation registry; in 12 countries the reported time lag varied from one week to 2months (table 22).

Table 22. Time lag between vaccination and reporting to a medical record or immunizationregistry. National seasonal influenza vaccination survey, March 2014 (n=27)

Countries TotalNo time lag, entered at the timeof vaccine administration

CZ,IS,LT,MT,SK,UK-ENG,UK-NI,UK-SC

8

1 week EE,NO,RO,SE,UK-WL,PT 63 weeks FI 11 month CY,IT,LV,NL 42 months HR 1More than 1 month

Three months now, in the future no time lag DK 1At national level coverage is collected annually ES 1At the end of the season SI 1During the year following the end of the flu LU 1

49

seasonGPs send in reports of vaccines administered to

payment office, the time may vary from immediatelyto months later

IE 1

The hospitals and the health centers are requiredto report until December

GR 1

We collect data twice in one season HU 1BE,DE,LI,PL,FR, BG- not applicable.

Six countries reported that it was possible to link of regional/national electronicimmunization registry data with medical records in General practitioner (Family doctor)clinics or hospitals or with influenza laboratory data. The data is presented in table 23.

Table 23. Link of regional/national electronic immunization registry with other medicalinformation. National seasonal influenza vaccination survey, March 2014 (n=6)

Country TotalLink of regional/national electronic

immunization registry with medical records in hospitalsLink exists DK,FI,ES,SE 4Link does not exist PT,NO 2

Link of regional/national electronic immunization registrywith medical records in General practitioner (Family doctor) clinics

Link exists DK,FI,ES,SE,NOa 5Link does not exist PT 1

Link of regional/national electronicimmunization registry with influenza laboratory data

Link exists DK,FI,SE 3Link does not exist ES,PT,NO 3

a Most of the GPs have an electronic patient record system that has integration to the national electronicimmunisation registry, but not all.

Comments:HR- Medical records are used here as a proxy name for seasonal influenza immunization reports collectedevery year following the vaccination season.CZ- entered to medical record, there is no immunization registry.FI- for administrative purposes can link without special permission, for research purposes need permissionwhich takes time.FR- Vaccine coverage assessed through the reimbursement of vaccine sale and administration, not throughmedical records.HU- every vaccinator has to report number of vaccinated persons.IT- Not at the national level but only at the Local Health Units level.LU- Medico-administrative data from the health insurance fund are available during the following year.MT- All vaccines registered manually at time of vaccination.PT- Only immunisation registry not linked to others in 2012/2013.SI- Reporting on vaccination coverage is done in April.ES- There are several electronic immunization registries at regional level. They have different characteristics.SE - For research purposes, an ethical permission is needed to link databases.

50

Numerator and denominator assessmentOf the 33 survey responding countries, only four (BE,IE,NO,PT) used survey methods toestimate influenza vaccination coverage for influenza season 2012-13. More detailedinformation on survey methodologies used, by country, is presented in table 24.

51

Table 24. Details for survey method used to assess vaccination coverage in EU/EEA countries in 2012-13 influenza season. National seasonalinfluenza vaccination survey, March 2014 (n=4)

Countries Type ofSurvey

Survey mode Samplingstrategy

Samplesize

Responserate(%)

Population groups to whomvaccination coverage was estimated

Comments

BE Individual In person Probabilitysampling;Cluster (EPI)

10000 3 Entire population;Adults aged between 18 and 65 years old;Adults aged more than 65 years old

IE Household

By telephone Nonprobabilitysampling;Quotas

1700 10 Adults aged between 18 and 65 years old;Adults aged more than 65 years old

Quota sample basedon age, gender andarea and pregnancy.risk groups will thenbe identified

NO Individual By telephone Probabilitysampling;Stratified(assessment,LQASa)

2000 6.1 Adults aged between 18 and 65 years old;Adults aged more than 65 years old; Otheradult age group: 16 years and older;Individuals with medical/risk conditions(clinical risk groups);Individuals with medical/risk conditions -other age group: 16 years and older

PT Household

By telephone Probabilitysampling;Stratified(assessment,LQASa)

2719 84 Entire population;Children and adolescents <15 years old;Children and adolescents; Individuals withmedical/risk conditions (clinical riskgroups)

aLot Quality Assessment Sampling

52

Numerator assessment

Eight countries (BG,CY,IS,LU,NO,PL,SK,PT) reported that they used pharmaceutical data forassessing the numerator in order to estimate influenza vaccination coverage for entirepopulation for 2012-13 influenza season. Seven of these countries use pharmaceutical datato measure vaccination coverage for entire population; in NO pharmaceutical data wereused to estimate vaccination coverage for individuals with medical/risk conditions andpersons 65 years and older (combined) (table 25).Twenty five countries (BE,HR,CZ,DK,EE,FI,FR,DE,GR,HU,IE,IT,LV,LI,LT,MT,NL,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL) did not use pharmaceutical data for influenza vaccinationcoverage assessment.

Table 25. Pharmaceutical data used to measure vaccination coverage in EU/EEA countries in2012-13 influenza season. National seasonal influenza vaccination survey, March 2014 (n=8)

Population groups/Countries Month/yearVaccine distribution data from industry- entire population

LUa Not indicatedPT 04/2013

Vaccine distribution data from national purchaser-entire populationCY 01/2014BG,NO,PT 04/2013IS 05/2013PL 04/2013SK 06/2013

Vaccine data by sales and distribution from pharmacies- entire populationCY 01/2014NO 04/2013SK,PT 06/2013Number of doses distributed from national purchaser intended for medical/risk conditions

and persons 65 years and older togetherNO 04/2013a -Wholesalers for pharmaceutical products.

Of the 33 participating countries 11 countries collect aggregate data on of the number ofvaccines administered (HR,CZ,IT,LT,MT,NL,RO,ES,UK-ENG,UK-SC,UK-WL) to assess thenumerator ; these data are also collected in IS,SK,HU,LV,SE,UK-NI,LU,PT in addition to otherdata used for numerator assessment. Three counties (BE,EE,GR) do not collect thisinformation (table 26).

Table 26. Vaccine data collection methods by country used in EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)

Countries TotalAggregate collection of number of vaccinesadministered

HR,CZ,IT,LT,MT,NL,RO,ES,UK-ENG,UK-SC,UK-WL

11

Aggregate collection of number of vaccinesadministered;

LV,SE,UK-NI 3

53

Payment/ reimbursement claimsAggregate collection of number of vaccinesdistributed (national purchaser);

BG,PL 2

Payment/ reimbursement claims DK,LI 2Aggregate collection of number of vaccinesadministered;Aggregate collection of number of vaccinesdistributed (national purchaser)

IS 1

Aggregate collection of number of vaccinesadministered;Aggregate collection of number of vaccinesdistributed (national purchaser);Aggregate collection of number of vaccines sales(private pharmacies);Payment/ reimbursement claims

SK 1

Aggregate collection of number of vaccinesadministered;Prescription data

HU 1

Aggregate collection of number of vaccinesdistributed (industry);Payment/ reimbursement claims

LU 1

Aggregate collection of number of vaccinesdistributed (national purchaser);Aggregate collection of number of vaccines sales(private pharmacies);Aggregated number of doses distributed from allwholesalers

NO 1

Aggregate collection of number of vaccinesdistributed (national purchaser);Payment/ reimbursement claims

IE 1

Aggregate collection of number of vaccines sales(private pharmacies);Payment/ reimbursement claims

DE 1

Actual numbers of vaccines given FI 1Target individual are personally invited to bevaccinated and receive a voucher for free vaccine.Denominator is the number of vouchers sent andnumerator the number of vouchers back forreimbursement

FR 1

Aggregate collection of number of vaccinated persons SI 1Aggregate collection of number of vaccinesadministered;Aggregate collection of number of vaccinesdistributed (national purchaser);Aggregate collection of number of vaccines

distributed (industry);Aggregate collection of number of vaccines sales

PT 1

54

(private pharmacies)Aggregate collection of number of vaccinesdistributed (national purchaser);Aggregate collection of number of vaccines sales(private pharmacies)

CY 1

None BE,EE,GR 3

Five countries collect numerator data weekly (FR,MT,UK-ENG, UK-SC, UK-WL); in three othercountries (LV,UK-NI, DK) these data are collected on a monthly basis; and in 17 countries(BG,CY,CZ,EE,LT,NO,RO,SE,HR,DE,IS,LU,NL,PL,SK,SI,ES) numerator data is collected once, atthe end of the influenza season (annual data collection at, or towards, end of season) (table27).

Table 27. Interval of numerator assessment in EU/EEA countries in 2012-13 influenzaseason. National seasonal influenza vaccination survey, March 2014 (n=32)

Countries Time specified

WeeklyFR,MT,UK-ENG, UK-SC, UK-WLa

MonthlyLV,UK-NI, DK

Every two monthsPT

Twice during the seasonHU In January and in AprilIT 31st of January and 15th of April

Once, at the end of influenza seasonBG,CY,CZ,EE,LT,NO,RO,SE

AnnuallyHR FebruaryDE no specific dateIS May each yearLU during the year thereafterNL 2013PL the second/third quarter of the yearSK May – JuneSI AprilES March each year

Different intervals for different groups whom vaccine is recommendedIE For HCWs and residents in long term care it was

collected twice during flu season in 2012-2013season, for elderly the data is requested monthlyintervals from national payment agency for thoseentitled to this service.

LI Children and adolescents annually, others rarely

55

OtherBE No regular monitoring takes place in BelgiumGR No regular monitoring takes place in Greece

a This information is collected, but not reported on a routine basis.FI-no data.EE- Vaccination data source: immunization reports presented by vaccinators every 3 months.

Denominator assessment

The details relating to the denominator assessment for each country are presented in table28. A denominator for children and adolescents is used in 14 countries; a denominator forindividuals with medical/risk conditions is available in seven countries; for residents of longterm care facilities, in four countries; for pregnant women, in nine countries; and for HCWs,in 12 countries.

Table 28. Denominator assessment in EU/EEA countries in 2012-13 influenza season.National seasonal influenza vaccination survey, March 2014 (n=33)

Assessment Population groups/countriesEntire population

Not used CZ,EE,FR,GR,IE,ES,UK-SCUsed CY,BE,BG,HR,DK,FI,DE,HU,IS,IT,LV,LI,LT,LU,MT,NL,NO,PL,

RO,SK,SI,SE,UK-ENG,UK-NI,UK-WL,PTPlease specify (e.g. population registries, Central statistic data, diseases registries and etc.)

CY,BE,BG,HU,LV,PL,RO,LT,IT,LU,MT,PT

National central statistic data

SI,SE,DK,FI,NO,LI National population registry/iesHR CensusDE Mandatory insured population

(i.e. 90% of total population)IS From the National ConsensusNL Central population statisticsSK The total number of populationUK-ENG GP registeredUK-NI Registered PopulationUK-WL Electronic medical records from

General PracticeChildren and adolescents

Not used BG,CY,CZ,EE,FI,FR,DE,GR,IS,IE,LT,LU,MT,NO,RO,ES,SE,UK-SC,PT

Used BE,HR,DK,HU,IT,LV,LI,NL,PL,SK,SI,UK-ENG,UK-NI,UK-WLPlease specify (e.g. population registries, Central statistic data, diseases registries and etc.)

BE,HU,LV,PL National central statistic dataHR censusDK,LI,SI National population registry/iesIT National Bureau of StatisticsNL Central population statistics

56

SKThe number of 0-15 years oldsout of the total number ofpopulation

UK-ENG GP registeredUK-NI Registered PopulationUK-WL Electronic medical records from

General PracticeAdults

Not used BG,CY,CZ,EE,FI,FR, GR,IE,LI,LT,LU,MT,NO,RO,ES,SE,UK-NI,PT

Used DE,BE,HR,DK,HU,IS,IT,LV,NL,PL,SK,SI,UK-ENG,UK-SC,UK-WLPlease specify (e.g. population registries, Central statistic data, diseases registries and etc.)

BE,HU,LV,PL Central statistics dataHR CensusDK,SI Population registriesIS >60 yearsDE Mandatory insured population

(i.e. 90% of total populationIT National Bureau of StatisticsNL Central population statisticsSK The number of 16-58 years olds

and 59 and more years olds outof the total population

UK-ENG GP registeredUK-SC GP medical records (65+)UK-WL Electronic medical records from

General PracticeIndividuals with medical/risk conditions (clinical risk groups)

Not used CY,BE,BG,HR,CZ,DK,EE,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,RO,SK,SI,ES,SE,PT

Used FI,FR,PL,UK-ENG,UK-NI,UK-SC,UK-WLPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

FI Drug insurance registerFR number of vouchers sent (see

commentsPL Diseases registersUK-ENG GP registeredUK-NI Registered PopulationUK-SC GP medical recordsUK-WL Electronic medical records from

General PracticePregnant women

Not used BE,BG,CY,CZ,DK,EE,FI,FR,DE,GR,IS,IE,LV,LI,LU,MT,NL,NO,SK,SI,ES,SE,PT

Used HR,HU,IT,PL, LT, RO,UK-ENG,UK-NI,UK-SC,UK-WL

57

Please specify (e.g. population registries, Central statistics data, diseases registries andetc.)

HR Health service statistics reportsHU Central statistics dataIT Number of live birthsPL Diseases registersRO GP medical recordsLT Number of live birthsUK-ENG GP registeredUK-NI Registered PopulationUK-SC GP medical recordsUK-WL Electronic medical records from

General PracticeHealth care workers

Not used BE,BG,CY,CZ,DK,EE,FI,FR,DE,IS,IT,LV,LI,LU,MT,NL,NO,SK,SI,SE

Used HR,GR,HU,IE, LT, PL,RO,ES,UK-ENG,UK-NI,UK-SC,UK-WL,PTPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

HR Health service statistics reportsGR Administrative method HCWs

from NHS registriesHU, PL,RO Central statistics dataLT -IE Based on denominator data

provided from units providingdata on numerator

ES Denominator provided byregions based on RegionalHealth System occupationalrecords

UK-ENG Occupational health recordsUK-NI Occupational HealthUK-SC Staff recordsUK-WL Aggregate notifications of

vaccinations given in NHS HealthBoard Occupational HealthDepartments

PT HCWs from NHS registriesEssential public sector workers

Not used BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

Used PLPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

PL Central statistics data

58

PrisonersNot used BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,

MT,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PTUsed PLPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

PL Central statistics dataResidents of long term care institutions

Not used BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IT,LV,LT,LU,MT,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC

Used IE,LI,PL,UK-WL,PTPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

IE Based on denominator dataprovided from units providingdata on numerator

LI Reports of long term careinstitutions, estimate only

PL Diseases registersUK-WL Medical records from General

PracticePT Aggregate number people in

each institutionEducational institutions

Not used BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL,PT

Used PLPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

PL Central statistics dataOther, please specify

Not used BE,BG,CY,HR,DK,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,MT,NL,PL,RO,SI,SE,UK-ENG,UK-WL

Used CZ,EE,LU,NO,SK,ES,UK-NI,UK-SCPlease specify (e.g. population registries, Central statistics data, diseases registries andetc.)

CZ Individuals with medical/riskconditions (clinical risk groups)plus people of age ≥65 togetherNumber of vaccineadministered, one summarynumber from health insurancecompany

EE ≥65 years of age; coverage=number of vaccinated people ingroup≥65/number of people in

59

this age groupLU Adults ≥ 65 years old; National

statistical office estimation for 1January (corresponding year).

NO Medical risk groups and allpersons ≥65 years together; Ithas been estimated that personsbelonging to risk groups(medical risk groups and persons≥65 years) comprise about 19%of the total population

SK The number of 16-58 years oldsand 59 and more years olds outof the total population

ES ≥64 years of age; The totalnumber of registered populationin each region

UK-NI Adults aged ≥65 years;Registered Population

UK-SC Unpaid carers; GP medicalrecords

Scientific studies on vaccination coverage

Three (FI, DE,UK-WL) of 33 countries reported that scientific studies on vaccination coveragewere undertaken in their countries. Details of these studies are specified in table 29.

Table 29. Details on scientific studies performed on vaccination coverage in EU/EEAcountries in 2012-13 influenza season. National seasonal influenza vaccination survey,March 2014 (n=3)Country Methods Availability of

geographicalinformation

systems (GIS)for studypurposes

Time frameand frequency

Target groups

FI Surveys for validation ofdata quality

- - -

DE Utilization ofreimbursement claimsdata, telephone surveys,face-to-face interviewsfollowing snowballingtechniques

No Depending on funding -specific researchquestion - often incombination with KAPquestions

Depending on theresearch question(pregnant women,elderly)

UK-WL We use vaccine uptakedata to monitor theeffectiveness ofinterventions to improve

No Weekly As indicated above

60

uptake

Comments:IE- The national telephone surveys are done every few years, the surveys of hospitals and residential facilitieswill be annual.ES-The results of the evaluation is published in the web page. These results are used in scientific studiesconducted by other researchers/institutions.

Vaccine safety monitoring

National Systems to monitor influenza vaccine safety (adverse events followingimmunization) in vaccinated individuals are available in all 33 countries (table 30): in 21countries case-based data (including age, sex and suspected symptoms) should be reported;in seven countries case-based data with a personal identifier and suspected symptomsshould be reported in two countries aggregate data (including age, sex and suspectedsymptoms) should be reported; in the UK-ENG and UK-WL the Yellow card reporting systemto MHRA is in place; in BE there is a national, general online notification system of adverseeffects of medicines.

Table 30. Availability of the system to monitor influenza vaccine safety (adverse eventsfollowing immunization) in vaccinated individuals at the national/regional level and linkageto immunisation registry in EU/EEA countries in 2012-13 influenza season. National seasonalinfluenza vaccination survey, March 2014 (n=33)

Countries TotalNational level

Yes, case based data including age, sex andsuspected symptoms should be reported

BG,HR,CZ,EE,FR, HU,GR,IS,IE,IT,LV,LT,LU,MT,NO,PL,ES,SE,UK-NI,UK-SC,PT

21

Yes, aggregated data including age, sex andsuspected symptoms should be reported

NL,SK 2

Yes, case based data with a personalidentifier and suspected symptoms shouldbe reported

CY,DK,FI,DE,LI,RO,SI 7

Other BEd,UK-ENGc,UK-WLc 3Data linkage to immunisation registry

Not possible BG,HR,CZ,EE,FR,DE,GR,HU,IE,IT,LV,LI,LT,LU,NO,PL,SI,ES,SE,UK-NI,UK-SC,PT, SK

23

Possible CY,DK,FI,IS,MT,NL,RO, 7Regional levela

Yes, aggregated data including age, sex andsuspected symptoms should be reported

SK, HU 2

Yes, case based data including age, sex andsuspected symptoms should be reported

BG,HR,CZ,EE,FR,GR,IS,IE,IT,LT,NO,PL,ES,UK-NI

14

Yes, case based data with a personalidentifier and suspected symptoms shouldbe reported

CY, LI,RO 3

61

No, there is no such system BE,DK,FI,DE,LV,MT,NL,SI,SE,UK-ENG,UK-SC,UK-WL,PT

13

Data linkage to immunisation registryNot possible BG,HR,CZ,EE,FR,GR,HU,

IE,LI,LT,NO,PL,SK,ESb,UK-NI15

Possible CY,IS,IT,RO 4aLU- No regional level existing, national monitoring for the whole country.b It is possible in some Regions.cYellow card reporting system to MHRA.dA national, general online notification of adverse effects of medicines..

The availability of the system to monitor influenza vaccine break-through* infections invaccinated individuals, and its availability to link these data with immunisation registry, wasreported by seven countries. Most countries (n=25) do not have such systems in place (table31).

Table 31. Availability of the system to monitor influenza vaccine break-througha infections invaccinated individuals and linkage to immunisation registryin EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalNo, there is no such system GR,BE,BG,CY,CZ,DKa,EE,FI,FR,HU,IE, IT,LV,LI,LT,

LU,PL,RO,SK,SI,SE,UK-ENG,UK-NI,UK-SC,ES25

Yes, aggregated should bereported to the national level

NL 1

Yes, case based data should bereported to the national level

HR,DE,IS,MT,NO,PT 6

Yes, case based data should bereported to the regional level

- 0

Other UK-WL 1Data linkage to immunisation registry

Not possible HR,DE,NO,PT 4Possible IS,MT,NL 3

a Break-through infection is defined as laboratory-confirmed influenza infection >14 days after seasonalinfluenza vaccination in the current season (i.e. vaccine failure).b There is no such system in place to routinely monitor break-through infection in DK, but it is possible to do itby data-linkage.

Is it mandatory to report adverse events following vaccination (AEFV) in 23 countries(CY,BG,HR,DK,EE,FI,DE,GR,HU,IS,IE,LV,LI,LT,NO,PL,RO,SK,SI,ES,SEa,UK-ENG,UK-NI,UK-WL); and in the remaining nine countries (BE,CZ,FR,IT,LU,MT,NL,UK-SC,PT ) report thisinformation is not mandatory (table 32).

Table 32. Report of adverse events following vaccination in EU/EEA countries in 2012-13influenza season. National seasonal influenza vaccination survey, March 2014 (n=33)

Countries TotalNot mandatory to report adverse events following vaccination

BE,CZ,FR,IT,LU,MT,NL,UK-SC,PT 9

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Mandatory to report adverse events following vaccination (AEFV)CY,BG,HR,DK,EE,FI,DE,GR,HU,IS,IE,LV,LI,LT,NO,PL,RO,SK,SI,ES,SEa,UK-ENG,UK-NI,UK-WL

23

Institution whom AEFV is reported (n=23)CY To the Pharmaceutical services of the MoH 1BG MoH and Bulgarian Drug Agency 1

HRCroatian Institute of Public Health and Agency for Medical Products andMedical Devices of Croatia 1

DK To the Danish Health and Medicines Authority 1EE To the State Agency of medicines 1FI National Institute for Health and Welfare 1DE local public health office -> regulatory authority 1GR National Agency for Medicines (EOF) 1

HUNational Center For Epidemiology and Directorate General of NationalInstitute of Pharmacy 1

IS Medical Agency 1IE to regulatory body- the Irish Medicines Board 1

LVCentre for Disease Prevention and Control of Latvia, State medicineAgency 1

LI National Agency for Therapeutic Products 1

LTIt is mandatory to perform adverse events to Centre for communicablediseases and AIDS and to National drugs control institution 1

NONorwegian Institute of Public Health on behalf of Norwegian MedicinesAgency 1

PL Medical doctors 1RO National Centre of Communicable Diseases Surveillance and Control 1SK State Institute of Drug Control, Regional Public Health Authorities 1SI Register for AEFI at National Institute of Public Health 1

ESto the Spanish Pharmacovigilance System. the information is received inthe Regional Center and uploaded to the National database (FEDRA) 1

SE The Swedish Medical Products Agency. 1UK-ENG MHRA 1UK-NI MHRA Yellow Card Scheme 1UK-WL The Medicines and Healthcare products Regulatory Agency (MHRA) 1UK-SC MHRA Yellow Card Scheme 1

aOnly mandatory to report unexpected and severe events AND for those responsible for health care services.

Studies on influenza vaccine safety and vaccine effectiveness

Of 33 survey participating countries five (DK,FI,IT,ES,UK-ENG) reported that they hadcarried out studies on influenza vaccine safety within the last five years and 16(HR,DK,FI,FR,DE,HU,IE,IT,NL,PL,ES,UK-ENG, UK-NI,UK-SC,UK-WL,PT) undertook vaccine effectiveness studies.Details and links to these studies presented in table 33 and 33a.

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Table 33. Scientific studies on influenza vaccine safety and vaccine effectiveness performedwithin the last 5 years. National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalStudies on influenza safety

Not performed BE,BG,HR,CY,CZ,EE,FR,DE,GR,HU,IS,IE,LV,LI,LT,LU,MT,NL,NO,PL,RO,SK,SI,SE,UK-NI,UK-SC,UK-WL,PT

28

Performed DK,FI,IT,ES,UK-ENG 5Time intervals for safety studies

Every year IT 1Other timeinterval

DK,FI,ES,UK-ENG 4

Product-specific safety studiesNot performed DK,IT,ES,UK-ENG 4Performed FI 1

Studies on influenza vaccine effectivenessNot performed BE,BG,CY,CZ,EE,GR,IS,LV,LI,LT,LU,MT,NO,RO,SK,SI,SE 17Performed HR,DK,FI,FR,DE,HU,IE,IT,NL,PL,ES,UK-ENG, UK-NI,UK-SC,UK-

WL,PT 16Time intervals for vaccine effectiveness studies

Every year DK,FI,DE,HU,IE,NL,ES,UK-ENG,UK-NI,UK-SC,UK-WL,PT 12Every other year IT,PL 2Other timeinterval

HR,FR 2

Product-specific safety studiesNot performed DK,FI,FR,DE,IE,IT,NL,ES,UK-ENG, UK-NI,UK-SC,UK-WL,PT 13Performed HR,HU,PL 3

64

Table 33a. Scientific studies on influenza vaccine safety and effectiveness and details for studies performed within the last 5 years. Nationalseasonal influenza vaccination survey, March 2014 (n=15)Country/ Link to

publicationStudy type Year Method Target groups

Study year 1HR/Link to publication

Effectiveness 2010-11 Case-effectiveness Entire populationNot published yet

DK/Link to publication

Effectiveness 2009-10 Register-based cohort study Risk groupshttp://www.ncbi.nlm.nih.gov/pubmed/22277542

DKLink to publication

Safety 2009/10 Register-based cohort study Pregnant womenhttp://www.ncbi.nlm.nih.gov/pubmed/22782418

DK/Link to publication

Safety 2009-10 Register-based cohort study Pregnant womenhttp://www.ncbi.nlm.nih.gov/pubmed/22551713

FI Safety - - -FR/Link to publication

Effectiveness 2011-12 Screening method Severe cases in ICUEurosurveillance, Volume 17, Issue 18, 03 May 2012

DE/Link to publication

Effectiveness Annual Screening methods, test-negativecase-control

Total population, persons aged ≥60 yrs

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19388HU Effectiveness 2008-09 Case control study Patients in age group ≥60 presenting with influenza-like

illness (meeting the EU ILI case definition) atparticipating GPs

IE/Link to publication

Effectiveness 2009-10; 2010-11;2011-12; 2012-13

Sentinel sites- part of IMOVEstudy

All population

https://www.hpsc.ie/hpsc/A-Z/Respiratory/Influenza/SeasonalInfluenza/Publications/InfluenzaVaccinationPublications/File,4511,en.pdf

IT/Link to publication

Effectiveness 2009-10; 2010-11;2011-12

Case control study General population

https://sites.google.com/site/epiflu/NL/Link to publication

Effectiveness 2012-13 Test-negative case-controlmethod

Swabbed medically attended ILI patients in the sentinelGP network.

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http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20399PL Effectiveness 2010-11 CC study-part of I-MOVE Entire populationES/Link to publication

Effectiveness cycEVA/2008-09

Design: test-negative case-controlstudy. Outcome: lab confirmedinfluenza

Elderly

http://dx.doi.org/10.1016/j.vaccine.2010.01.054UK-ENG/Link to publication

Effectiveness 2012-13 TNCC method Vaccine target groupshttp://www.ncbi.nlm.nih.gov/pubmed/23399421

UK-SC/Link to publication

Effectiveness 2012-13 Test-negative All population (stratified by age and clin at risk)UK mid-season analysis http://www.ncbi.nlm.nih.gov/pubmed/23399421

UK-WL/Link to publication

Effectiveness 2011, 2012, 2013 Swab-negative case-control(Wales provide data for acollaborative UK study)

Adults aged 65y and older and those aged 6m to 64y atclinical risk

http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20389http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19791http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20389

PT/Link to publication

Effectiveness EuroEVA - -I-move study

Study year 2FR/Link to publication

Effectiveness Every year since2008

Case control study -

I move studyIT - - - General populationNL 2006-07 to 2010-11 Swabbed medically attended ILI patients in the sentinel

GP network.HU 2009-10 Case control study using

systematic sampling, testnegative design (comparinginfluenza-positive to influenzalaboratory-negative patients)

Practitioners interviewed and collected swabs from asystematic sample (in age group 60+: all ILI cases, in 18-59: the first and second eligible patient in every singleweek) of patients presenting with influenza-like illness(meeting the EU ILI case definition).

Link to publication http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000388

66

PL 2011-12 Entire populationES/Link to publication

CycEVA-2009-10;SISS-2009-10

All population

www.biomedcentral.com/content/pdf/1471-2458-11-899.pdfUK-SC/Link to publication

2011-12 Test-negative All population (stratified by age and clinical risk group)UK end-of-season http://www.ncbi.nlm.nih.gov/pubmed/23399424

Study year 3NL 2009-10 Cases were patients hospitalised with laboratory-

confirmed 2009 A/H1N1 influenza infection betweenNovember 16, 2009 and January 15, 2010.

PL 2012-13 Entire populationES/Link to publication

CycEVA-2010-11;SISS-2010-11

All population; target groups for vaccination; agegroups; previous vaccination

Effectiveness of the 2010/11 seasonal trivalent influenza vaccine in Spain: preliminary results of a case-control study. Euro Surveill.2011;16(11):1-6.pii=19820. Available from: http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19820Effectiveness of the 2010–11 seasonal trivalent influenza vaccine in Spain: cycEVA study. Vaccine, 2012, 30: 3595-3602.


2010-11 Comparison of differentmethods

All population (stratified by age and clinical risk group)

Scotland end-of-season http://www.ncbi.nlm.nih.gov/pubmed/23933371Study year 4

HU/Link to publication

2010-11 As above As abovehttp://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0027622;http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19818

ES/Link to publication

CycEVA-2011-12;SISS-2011-12

All population; target groups for vaccination; agegroups; time since vaccination

Early estimates of the effectiveness of the 2011/12 influenza vaccine in the population targeted for vaccination in Spain, 25 December2011 to 19 February 2012. Euro Surveill. 2012;17(12):1-6. Available from:http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20129Effectiveness of influenza vaccine against laboratory-confirmed influenza, in the late 2011–2012 season in Spain, among populationtargeted for vaccination. BMC Infectious Diseases 2013 13:441. Available from: http://www.biomedcentral.com/1471-2334/13/441

UK-SC/ 2010-11 Screening method Severe influenza cases

67

Link to publication England and Scotland http://www.ncbi.nlm.nih.gov/pubmed/23591102Study year 5

HU/Link to publication

2011-12 As above As abovehttp://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20281;http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20146;http://www.eurosurveillance.org/ViewArticle.aspx?ArticleId=20390

ES/Link to publication

- CycEVA-2012-13;SISS-2012-13

- All population; target groups for vaccination; agegroups

Estimating the 2012/13 influenza vaccine effectiveness using the cycEVA study, the Spanish component of the multicentre I-MOVEstudy. European Scientific Conference on Applied Infectious Disease Epidemiology (ESCAIDE). Stockholm, 5-7 November 2013.


2010-11 Test negative All population (stratified by age and clinical risk group)UK mid-season http://www.ncbi.nlm.nih.gov/pubmed/21329644

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Section IV: VACCINE PROCUREMENT AND DELIVERY

Information on number of doses for influenza season 2012-13 purchased, distributed, usedor estimated varied by countries; overall 22 countries were able to provide this information(table 34).

Table 34. Vaccine procurement in EU/EEA countries in 2012-13 influenza season. Nationalseasonal influenza vaccination survey, March 2014 (n=22)

Country Number of dosesPurchaseda Distributed Used Estimated

BG 194398 NK NK NKHR 450000 445000 288440 288440CY 91640 76708 76708 76708DK 575000 575000 NK NKFI 1200000 900000 900000 900000DE 13322945 NK NK NKHU 1500000 1300000 1000000 NKIE 749992 702027 659596 749992IT NK NK 8825063 NKLV 30500 23640 9201LT 97177 97177 95136 95136MT 75200 75200 75200 75200NL 3950000 3735000 3490000 NKNO 645894 541771 526134 526134PL 1500000 1500000 910000 1410000PT 1900000 1900000 NK NKRO 1000000 1000000 904251 2746000SK 262996 249684 249684 249684SI 140755 121491 88000 100000UK-ENG NK 17566957 11914798 11914798UK-NI 480000 NK NK 437000UK-SC 1156463 NK NK NK

a If parallel systems exist (public/private), please provide if possible an estimate for overall number of dosespurchased in your country.Not known (NK)- UK-WL,CZ,EE,FR,IS,GR,BE,ES,SE,LI.Not provided- LU.

Comments on vaccine procurement:CZ -Purchases of vaccine for 5.8 % of population.EE -Influenza vaccination is not included in to the national immunization schedule. There is no seasonalinfluenza vaccination program in Estonia. All people have to pay for influenza vaccines and vaccination fromtheir pockets. All vaccinators are obligated to report the number of vaccinated people.FI -Private sector also sells influenza vaccines which we do not keep calculus on.FR Distributed= vaccines purchased less vaccines returned back by the office.DE-This is the number of prescribed vaccine doses in the public market (around 90% of the total population).

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IE- Refers to doses purchased by national authority and distributed. Additional private supplies would havebeen used by pharmacies or provided to GPs for private patients. But we do not have any data on this atmoment (it is requested).LV- No. of doses purchased and distributed - obtained from companies representatives in LV (GSK, Sanofi,Abbott). No complete data of No. of doses used.MT- This year all doses were utilised as there was an initiative to vaccinate persons visiting Out-PatientsDepartment at the General Hospital.PT- Vaccines are both purchased by NHS for free vaccination and sold in pharmacies.SI- No of doses used is actually no of persons reported to be vaccinated. Estimated number of doses issomewhere between this number and number of doses distributed.ES- Each Region purchase, distribute and administer their own vaccines. This information is not usuallycollected at national level.UK-ENG -This is based data collected on GP registered population and HCWs collected through the Informsystem and will not include information on doses of vaccine administered in non-primary health care settings.UK-NI -This includes only those provided by the NHS, not private supply.UK-SC No exact data on numbers distributed/used: estimated 2% wastage annually (i.e. 98%distribution/usage of purchased vaccines).UK-WL -During 2012-13 trivalent seasonal influenza vaccine was purchased directly from pharmaceuticalcompanies by general practices at an individual practice level. Central collation of purchasing information wasnot possible.

The amount of vaccines purchased was not sufficient to cover vaccination for recommendedpopulation groups in one (HR) of the 21 countries. Four countries (DE,IT,LI,ES) reported thatvaccine shortages and/or stock-outs during the last influenza season affected vaccinationcoverage in their countries (table 35).

Table 35. Amount of vaccines purchased to cover vaccination for recommended populationgroups and vaccine shortages and/or stock-outs in 2012-13 influenza season. Nationalseasonal influenza vaccination survey, March 2014

Country TotalAmount of vaccines purchased (n=21)

Amount not sufficient HR 1Amount sufficient BE,CZ,DK,FI,FR,IE,IT,LI,LT,MT,NL,NO,PT,SK,SI,ES,SE,

UK-ENG,UK-NI,UK-SC20

Vaccine shortages and/or stock-outs that affected vaccination coverage (n=28)Vaccination coveragenot affected

CY,BE,HR,CZ,DK,EE,FI,FR,HU,IS,IE,LT,MT,NL,NO,PL,RO,SK,SI,SE,UK-ENG,UK-NI,UK-SC,UK-WL

24

Vaccination coverageaffected

DEa,ITb,LIc,ESd 4

aBegripal und Fluad.bSuspension from the market of some vaccine lots of two different brands due to quality control check.cOne supplier had to withdraw his product for impurities.dThere were two incidents in Crucell and Novartis that affected several Regions.

Vaccine products used in 2012-13 among MSs, by type of vaccine, product name, andspecific population group/s for which it was used, are detailed in table 36. The trivalentinactivated non-adjuvanted vaccine (TIV) was the most commonly used vaccine in theinfluenza season 2012-13; overall this vaccine have been used in 30 countries(CY,BE,BG,HR,CZ,DK,EE,FI,FR,DE,GR, IS,IE,IT,LI,LT,MT,NL,NO,PL,PT,RO,SK,SI,SE,UK-ENG,UK-NI,UK-SC,UK-WL,ES). Trivalent inactivated adjuvanted vaccines (aTIV) were used in eight

70

countries (DE,IT,LI,PL,UK-SC,UK-WL,HU,ES) in 2012-13. Trivalent live attenuated nasalvaccine (LAIV) was available in four countries (DE,SE,UK-NI,UK-WL) and Quadrivalentinactivated non-adjuvanted vaccine (QIV) was not used in 2012-13.

Table 36. Vaccine products used and population groups targeted in 2012-13 influenzaseason in EU/EEA countries. National seasonal influenza vaccination survey, March 2014(n=31)

Country Type of vaccine /Product name Target groupsTrivalent inactivated non adjuvanted vaccines (TIV)

Used CY,BE,BG,HR,CZ,DK,EE,FI,FR,DE,GR,IS,IE,IT,LI,LT,MT,NL,NO,PL,PT,RO,SK,SI,SE,UK-ENG,UK-NI,UK-SC,UK-WL,ES

Not used HUCY GaxoSmithKline;

Sanofi PasteurThose with medical condition/s;Older adults (e.g. ≥60/65 years);Pregnant women;Health Care Workers

BE Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur;Novartis (non adjuvanted);Other manufacturer: Janssen-Cilag

Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;

Residents of long stay care facilities;Health Care Workers

BG Abbott healthcare;Sanofi Pasteur

Older adults (e.g. ≥60/65 years);Those with medical condition/s;Residents of long stay care facilities;Health Care Workers;Other occupational groups

HR Sanofi Pasteur Older adults (e.g. ≥60/65 years);Those with medical condition/s;Residents of long stay care facilities;Health Care Workers

CZ Abbott healthcare;Sanofi Pasteur

Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);

Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

DK GlaxoSmithKline;Sanofi Pasteur

Older adults (e.g. ≥65 years);Those with medical condition/s;Pregnant women;Other target group: The vaccines maybe given to all individuals on their owncost

71

EE Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur

Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

FI GlaxoSmithKline;Sanofi Pasteur

Children and adolescents;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Health Care Workers;Other target group: Close vicinity /household contacts

FR Abbott healthcare;Sanofi Pasteur;Novartis (non adjuvanted);Other manufacturer: Pierre Fabre;GlaxoSmithKline

Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

DE Abbott healthcare;Baxter;GlaxoSmithKline;Pfizer/CSL Australia;Sanofi Pasteur;Novartis (non adjuvanted)

Children and adolescents;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

GR Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur;Novartis (non adjuvanted)


Residents of long stay care facilities;Health Care Workers;Other occupational groups

IS Sanofi Pasteur Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

IEa GlaxoSmithKline;Sanofi Pasteur

Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups;Other target group: GSK product was

72

procured by pharmacies for privatepatients (we are informed)

IT Abbott healthcare;GlaxoSmithKline; Sanofi Pasteur;Novartis (non adjuvanted);Other manufacturer: Kedrion


LI GlaxoSmithKline;Sanofi Pasteur;Novartis (non adjuvanted)

Children and adolescents;Older adults (e.g. ≥60/65 years);Those with medical condition/s;

Pregnant women;Residents of long stay care facilities;Health Care Workers

LT Sanofi Pasteur Children and adolescents;Those with medical condition/s;Health Care Workers

MT Sanofi Pasteur Children and adolescents;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Residents of long stay care facilities;Health Care Workers;Other occupational groups

NL Abbott healthcare;Sanofi Pasteur;

Older adults (e.g. ≥60/65 years);Those with medical condition/s

NO Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur

Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;

Health Care Workers;Other occupational groups

PL Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur;Novartis (non adjuvanted)

Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;

Residents of long stay care facilities;Health Care Workers;

73


PT Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur

Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);

Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

RO GlaxoSmithKline Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;


SK Abbott healthcare;GlaxoSmithKline;Sanofi Pasteur

Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups;Other target group: Residents of socialcare facilities

SI Sanofi Pasteur Children and adolescents;Healthy adults;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers;Other occupational groups

SE b Abbott healthcare;Baxter;GlaxoSmithKline;Sanofi Pasteur


74

UK-ENG Abbott healthcare;GlaxoSmithKline;Pfizer/CSL Australia;Sanofi Pasteur;Novartis (non adjuvanted)

Children and adolescents;Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers

UK-NI Sanofi Pasteur;Novartis (non adjuvanted)

Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers

UK-SC Abbott healthcare;GlaxoSmithKline;Pfizer/CSL Australia;Sanofi Pasteur;Novartis (non adjuvanted)

Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers

UK-WL Abbott healthcare;Baxter;GlaxoSmithKline;Pfizer/CSL Australia;Sanofi Pasteur;Novartis (non adjuvanted)



Trivalent inactivated adjuvanted vaccines (aTIV)Used DE,IT,LI,PL,UK-SC,UK-WL, HU ,ESNot used CY,BE,BG,HR,CZ,DK,EE,FI,FR,GR, IS,IE,LT,MT,NL,NO,PT,RO,SK,SI,SE,

UK-ENG,UK-NIDE Crucell (virosomal vaccines);

Novartis (adjuvanted/Squalene(MF59)

Older adults (e.g. ≥60/65 years)

IT Crucell (virosomal vaccines);Novartis (adjuvanted/Squalene(MF59)

Children and adolescents;Older adults (e.g. ≥60/65 years)

HU GlaxoSmithKline;Omnivest

Children over 3 years and adolescents;Older adults (e.g. ≥60/65 years);Those with medical condition/s;

Pregnant women;Residents of long stay care facilities;

Health Care Workers;Other occupational groups

LI Crucell (virosomal vaccines);Novartis (adjuvanted/Squalene(MF59);Other manufacturer: Abott

Children and adolescents;Healthy adults; Older adults (e.g. ≥60/65years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;

Health Care Workers;

75

PL Other manufacturer: Berna Biotech Healthy adults

UK-SC Crucell (virosomal vaccines) Older adults (e.g. ≥60/65 years);Those with medical condition/s;Pregnant women;Residents of long stay care facilities;Health Care Workers

UK-WL Crucell (virosomal vaccines) Older adults (e.g. ≥60/65 years);Those with medical condition/s;Residents of long stay care facilities

Trivalent live attenuated nasal vaccine (LAIV)Used DE,SE,UK-NI,UK-WLNot used BE,BG,HR,CY,CZ,DK,EE,FI,FR,GR,HU,IS,IE,IT,LI,LT,MT,NL,NO,PL,PT,RO,SK,SI,ES,UK

-ENG,UK-SCDE Astra Zeneca Other target group: children aged 2-6

years with medical conditionsSE b Astra Zeneca Children and adolescentsUK-NI Astra Zeneca Children and adolescents with medical

conditionsUK-WL Astra Zeneca Those with medical condition/s

Quadrivalent attenuated nasal vaccine (LAIV)Used -Not used BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LI,LT,MT,NL,NO,PL,PT,RO,SK,SI,

ES,SE,UK-ENG,UK-NI,UK-SC,UK-WLQuadrivalent inactivated non-adjuvanted vaccine (QIV)

Used -Not used BE,BG,HR,CY,CZ, EE,DK,FI,FR,DE,GR,HU,IS,IE,IT,LI,LT,MT,NL,NO,PL,PT,RO,SK,SI,

ES,SE,UK-ENG,UK-NI,UK-SC,UK-WLOther products used

Used BE,ESNot used BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LI,LT,MT,NL,NO,PL,PT,RO,SK,SI,SE,UK

-ENG,UK-NI,UK-SC,UK-WLBE Trivalent inactivated intradermal vaccine

Intanza (Sanofi Pasteur MSD)Age group / medical conditions

ES Trivalent inactivated intradermal vaccineIntanza (Sanofi Pasteur MSD)

≥ 65 years of age / medicalconditions

a Sanofi Pasteur product procured by national agency, we believe that GSK (Fluarix) was procured privately bysome pharmacies for private patients.b TIVs are mostly used. Vaccines are procured before the influenza season by each county separately. LAIVvaccines were available season 2012-2013, but it is not known to what extent they were used.LU,LV –No data.

The ECDC information site on influenza vaccines

76

(http://ecdc.europa.eu/en/healthtopics/seasonal_influenza/vaccines/Pages/influenza_vaccination.aspx) have been used in eighteen countries(CY,BE,BG,EE,FI,GR,HU,IS,IE,IT,LI,MT,PL,PT,RO,SE,UK-NI,UK-WL); in the remaining 13countries (HR,CZ,DK,FR,DE,LT,NL,NO,SK,SI,ES,UK-ENG,UK-SC) this information have not beenused.

In most countries influenza vaccine administration was most frequently given in Generalpractitioner’s (Family doctors) surgeries, hospitals and workplaces, reported by 31, 23 and20 countries respectively (table 37).

Table 37. The main health care settings where influenza vaccine was administered bycountry. National seasonal influenza vaccination survey, March 2014 (n=33)

Country Health care setting TotalBE,DE,HU,LI General Practitioners (Family doctors) surgeries;

Hospitals;Workplaces;Paediatricians

4

DK,EE,MT General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Walk-in clinics;Paediatricians

3

NL,RO General Practitioners (Family doctors) surgeries 2ES, UK-NI General Practitioners (Family doctors) surgeries;

Hospitals;Workplaces

2

FI,FR General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Well-baby clinics;Paediatricians;

2

BG General Practitioners (Family doctors) surgeries;Hospitals;Paediatricians; Other:Immunization centres

1

GR General Practitioners (Family doctors) surgeries;Hospitals;Walk-in clinics;

Paediatricians

1

LU General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Paediatricians;Other: medical specialist's private practices and occupationalhealth services

1

SK General Practitioners (Family doctors) surgeries;Hospitals;

1

77

Workplaces;Paediatricians;Other: Social care facilities

SI General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Paediatricians;Other: Vaccination clinics on regional units of NIPH

1

UK-WL General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Pharmacies

1

UK-SC General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Pharmacies;

Walk-in clinics

1

IE General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Pharmacies;Walk-in clinics;Other: in residential care facilities

1

UK-ENG General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Schools;Pharmacies;Supermarkets;Walk-in clinics;Well-baby clinics;Paediatricians;Other: Antenatal clinics

1

IS General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Schools;Walk-in clinics;Well-baby clinics

1

NO General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;Walk-in clinics;Other: Public Health Services

1

HR General Practitioners (Family doctors) surgeries;Hospitals;Workplaces;

1

78

Walk-in clinics;Paediatricians;Other: Institutes of Public Health

CZ General Practitioners (Family doctors) surgeries;Paediatricians;

Other: vaccination centres

1

IT General Practitioners (Family doctors) surgeries;Paediatricians;Other: vaccine services in local Health Units

1

SE General Practitioners (Family doctors) surgeries;Workplaces;Walk-in clinics;Paediatricians

1

PL General Practitioners (Family doctors) surgeries;Workplaces;Walk-in clinics;Well-baby clinics

1

LT Hospitals;General Practitioners (Family doctors) surgeries

1

CY General Practitioners (Family doctors) surgeries;Hospitals;Walk-in clinics;Well-baby clinics;Paediatricians

1

PT Hospitals;Workplaces;Pharmacies;Walk-in clinics

1

LV-no data.

Doctors and nurses were reported as the most common health care workers whoadministered influenza vaccines in all 32 countries; in four countries (IE,PT,UK-WL,UK-ENG)vaccine was also administered by pharmacists (table 38).

Table 38. Health care worker professionals who administered influenza vaccines in 2012-13influenza season in EU/EEA countries. National seasonal influenza vaccination survey, March2014 (n=32)

Country TotalDoctors BE,HR,CZ,DE,GR,HU,SI 7Doctors;Nurses

BG,CY,DK,EE,FI,FR,IS,IT,LI,LT,LU,MT,NO,PL,RO,SK,ES,SE,UK-NI,UK-SC

20

Doctors;Nurses;Others: GP's assistants

NL 1

Doctors;Nurses;Pharmacists

IE,PT,UK-WL 3

79

Doctors;Nurses;Pharmacists;Others: Midwives

UK-ENG 1

LV-no data.

Of 25 responding countries 17 reported that special protocols were required (e.g. license,standing order) if vaccine was administered by anyone other than a doctor (table 39).

Table 39. The need of special protocol (e.g. licence, standing orders) for influenza vaccineadministration in 2012-13 influenza season in EU/EEA countries. National seasonal influenzavaccination survey, March 2014 (n=25)

Country TotalNo need of specialprotocol

CY,FI,IS,LI,LT,MT,NL,PT 8

The special protocol isrequired

BG,DK,EE,FR,IE,IT,LU,NO,PL,RO,SK,ES,SEa,UK-ENG,UK-NI,UK-SC,UK-WL

17

aA binding regulation (SOSFS 2000:1) regulates the ordination of vaccines by nurses. This limits the ordinationto groups included in national vaccination recommendations. Furthermore, not all nurses are allowed toprescribe influenza vaccines, only those with formal competence.BE,HR,CZ,DE,GR,HU,LV,SI- not applicable.

Most countries (n=23) do not provide financial incentives to those administering vaccine inorder to achieve higher vaccination coverage; in ten countries financial incentives werereported and these are specified in table 40.

Table 40. Financial incentive provided to vaccine administrators to achieve high vaccinationcoverage for influenza vaccine in 2012-13 influenza season in EU/EEA countries. Nationalseasonal influenza vaccination survey, March 2014 (n=33)

Country/Comment if financial incentive existNo financial incentive BE,BG,HR,DK,EE,FI,DE,GR,HU,IS,IT,LI,LT,LU,MT,NL,NO,

PL,PT,RO,SK,SI,ES,SEa

There is financialincentive

CY,CZ,FR,IE,LV,UK-ENG,UK-NI,UK-SC,UK-WL

CY The financial incentive is only for the Paediatricians and GPsworking in the private sector as they are paid the full cost of thevaccine plus what they charge for the visit.

CZ Some bonus payment for GPs that achieve specified level ofvaccination coverage among registered patients.

FR General practitioner can obtain an additional remuneration basedon public health objectives, which include influenza immunizationcoverage among their at-risk patients.

IE They are paid for vaccine administration.UK-ENG GPs are reimbursed for the cost of the vaccine and receive a flat

rate amount per vaccine administered. There are also performancerelated payments if certain coverage rates are achieved.

UK-NI GPs are paid per vaccine given.

80

UK-SC For ≥65s increased payment per patient if uptake of 75% or over isachieve.

UK-WL Quality Outcomes Framework, which specifies a target for a subsetof at-risk patients, but this, is lower than the 75% recommendedtarget.

a It is possible that some individual counties used financial incentives to increase coverage and/or fed backinformation on coverage.LV-no data.

Mechanisms to provide feedback information relating to vaccination coverage achieved torespective vaccinator/vaccinating clinic was reported by seven countries; most countriesindicated that there is no such mechanism in their countries (table 41).

Table 41. Mechanism to feedback on vaccination coverage achieved to respectivevaccinator/vaccinating clinic. National seasonal influenza vaccination survey, March 2014(n=33)

Country/Comment if feedback mechanism on vaccination coverage achieved

to vaccinators existsThere is nomechanism

BE,BG,HR,CY,CZ,DK,EE,FI,DE,GR,HU,IS,IE,IT,LI,LT,LU,MT,NL,NO,PL,RO,SK,SI,ES,SE

There is amechanism

FR,LV,PT,UK-ENG,UK-NI,UK-SC,UK-WL

FR Information about the immunization coverage rates is providedthrough several channels (media, article ...)

PT Vaccination coverage is available at each level.UK-ENG Collection of vaccine uptake data is automated and viewable on line.

Local immunisation coordinators can provide feedback at GP level oncomparative performance, and whether individual sites have met.

UK-NI Annual Reports.UK-SC Health boards have access to weekly practice level data on uptake

based on electronic GP records and provide feedback to individualpractices.

UK-WL General practice level reporting and feedback is provided by PublicHealth Wales.

LV-no data.

Comments on vaccine procurement and delivery:EE -All vaccinators are obligated to report the number of vaccinated people.IE -vaccine is distributed by the National Cold Chain distribution network.ES-A joint procurement agreement was conducted coordinated from the MoH. A total of 16 out of 19 Regionsand other national institutions participated.

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Section V: PROMOTING SEASONAL INFLUENZA VACCINATION

Communication with general public

Specific information materials (table 42) for the general public existed in 22 countries.Specific information for other population groupspregnant women or individuals withchronic medical conditions existed in 19 and 24 countries respectively. Most countries alsohad information materials for those with ≥65 years of age.

Table 42. Information campaigns for seasonal influenza vaccination that targets the generalpublic and other specific population groups in 2012-13 influenza season in EU/EEAcountries. National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalGeneral public

Yes BE,BG,HR, EE,FI,FR,GR,HU,IS,IT,LV,LI,LU,MT,PL,PT,RO,SK,SI,ES,UK-NI,UK-WL

22

No CY,CZ,DK,DE,IE,LT,NL,NO,SE,UK-ENG,UK-SC 11Population over 65

Yes BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,IS,IE,IT,LI,MT,NO,PL,PT,SI,ES,SE,UK-NI,UK-SC,UK-WL,SK

26

No HU,LV,LT,LU,NL,RO, UK-ENG 7Pregnant women

Yes BE,HR,CY,DK,FI,FR,DE,GR,IS,IE,IT,LI,MT,NO,PT,SI,UK-NI,UK-SC,UK-WL 19No BG,CZ,EE,HU,LV,LT,LU,NL,PL,RO,SK,ES,SE,UK-ENG 14

Clinical riskYes BE,BG,HR,CY,CZ,DK,FI,FR,DE,GR,IS,IE,IT,LI,MT,NO,PL,PT,SI,SE,

UK-NI,UK-SC,UK-WL, SK,24

No EE,HU,LV,LT,LU,NL,RO,ES,UK-ENG 9Others

Yes HR, FI, SI 3No BE,BG,CY,CZ,EE,DK,FR,GR,HU,IS,IT,LV,LI,LT,LU,NL,NO,PL,RO,SK,ES,SE,

DE,IE,MT,PT,UK-ENG,UK-SC,UK-WL, UK-NI30

HR All population through media 1FI Close vicinity / Household contacts 1SI Children < 2 years old 1

Various media campaigns (radio, TV or newspapers) were used in all 30 countries during2011-12 influenza season. Detailed information by country is specified in table 43.

Table 43. Sources used to inform the general public in 2012-13 influenza season in EU/EEAcountries. National seasonal influenza vaccination survey, March 2014 (n=30)

Sources of information Country TotalRadio;TV;Newspapers;Leaflets;

BG,DK,IE,IT,ES,SE,UK-SC 7

82

Posters;WebsiteRadio;Newspapers;Leaflets;Posters;

Website

LI,LU,PL 3

Leaflets;Posters;Website

DE,UK-NI 2

Leaflets;Website;

NO,SI 2

Newspapers;Leaflets;Posters;Website

FI,FR 2

Radio;Newspapers;Website

PT,SK 2

Posters LV 1Radio;Leaflets;Posters;Website

BE 1

Radio;Newspapers;Leaflets;

Posters;Website;Other: Social media and sponsorshipof national weather updates on oneTV channel

UK-WL 1

Radio;TV;

Leaflets;Website

HU 1

Leaflets;Posters;Other: press conference, discussionwith experts

CZ 1

Radio;TV;Newspapers;Leaflets;Posters;Website;Other: influenza forum for HCW

EE 1

83

LT,NL,UK-ENG-Not applicable.

Media campaigns were sponsored by the national health authorities in 26 countries and bythe pharmaceutical sector in seven countries. Details are presented in a table 44.

Table 44. Sponsors of seasonal influenza vaccination media campaigns for public in 2012-13influenza season in EU/EEA countries. National seasonal influenza vaccination survey, March2014 (n=30)

Country TotalNational / Regional health authority; BE,DK,EE,FI,FR,DE,IS,IT,LI,LU,

NO,RO,SK,SI,ES,SE,UK-SC,UK-WL18

National / Regional health authority;Pharmaceutical sector;

BG,CZ,IE 3

National / Regional health authority;Pharmaceutical sector;Public service announcementa

PL 1

National / Regional health authority;Public service announcementa

GR,MT 2

Pharmaceutical sector LV 1Public service announcementa HR,CY,HU,PT,UK-NI 5

aAdvertisement content and production is provided by government, including national health.LT,NL,UK-ENG- Not applicable.

Radio;TV;Newspapers;Leaflets;Website

HR 1

Radio;TV;Newspapers;Posters;Website

MT 1

Radio;TV;Newspapers;Website

IS 1

Radio;TV;Website

RO 1

TV;Newspapers;Leaflets;

CY 1

TV;Newspapers;Leaflets;Posters;Website

GR 1

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Comments on vaccination information campaigns:EE -The Ministry of Social Affair and Health Board are the main organizers of seasonal influenza informationcampaigns.IE-Pharmacists and some large pharmacy chains did some additional local advertisements.LT -there are no information campaigns, because there are no financial and human recourses.NL- There is no campaign, but target groups are invited to be vaccinated and receive information through ainvitation letter and leaflet, and can find additional information on a website.SI-It is actually not sponsored campaigns but proactive communication of NIPH with media.ES-A small promotion is done at national level. Main promotion campaigns are mainly designed and conductedat regional level.SE-The county medical officer is responsible for media campaigns.LV-There was no special vaccination campaign with the separate budget, however a lot of work has been doneas usually to communicate general public and professionals using websites, press realises, interviews tonewspapers, TV, radio un letters to GPs.

Communication with health professionals

Specific information materials (table 45) for health professionals regarding seasonalinfluenza vaccination (e.g. leaflets, posters) existed in 21 countries for the 2012-13 influenzaseason. Professional medical societies and website were the most common source ofinformation (in 11 and 12 countries respectively).

Table 45. Information campaigns for seasonal influenza vaccination that targeted healthcare workers in 2012-13 influenza season in EU/EEA countries. National seasonal influenzavaccination survey, March 2014 (n=33)

Country TotalYes BE,BG,HR,CY,EE,FI,FR,DE,GR,IS,IE,IT,LI,LU,MT,RO,SI,ES,

UK-NI,UK-SC,UK-WL21

No CZ,DK,HU,LV,LT,NL,NO,PL,PT,SK,SE,UK-ENG 12

Sources of information (n=21)Leaflets;Other: Letter from theMinistry of Health to allhealth care professionals

CY 1

Leaflets;Posters;Website

UK-NI 1

Leaflets;Posters;Website;E-based learningmodules;Professional medicalsocieties

ES,UK-WL 2

Leaflets;Posters;Website;National medicalpublications

DE 1

Leaflets; UK-SC 1

85

Posters;Website;Other: flu championsLeaflets;Posters;Website;Professional medicalsocieties;National medicalpublications

IT,LI 2

Leaflets;Website

SI 1

Newspapers;Leaflets;Posters;Professional medicalsocieties;National medicalpublications

FI 1

Other: Letter fromministry of health tohospitals and long-termcare

FR 1

Posters LU 1Posters;Professional medicalsocieties

MT 1

Posters;Website

BE 1

Professional medicalsocieties;

HR 1

Radio; TV;Newspapers;Leaflets;Posters;Website;Professional medicalsocieties

EE 1

Radio;TV;Newspapers;Leaflets;Posters;Website;Professional medicalsocieties;National medicalpublications

IE 1

Radio;TV;Newspapers;

BG,IS 2

86

Website;Professional medicalsocieties;National medicalpublicationsTV;Leaflets;

Posters;Website;Professional medicalsocieties;National medicalpublications

GR 1

Website;Professional medicalsocieties

RO 1

The ECDC promotional materials to support information campaigns on seasonal influenzavaccination(http://ecdc.europa.eu/en/healthtopics/seasonal_influenza/communication_toolkit/Pages/communication_toolkit.aspx) have been used in eight countries (BG,EE,GR,HU,IE,IT,PT,UK-WL);the details are provided in table 46.

Table 46. Use of ECDC promotional materials to support information campaigns on seasonalinfluenza vaccination in 2012-13 influenza season in EU/EEA countries. National seasonalinfluenza vaccination survey, March 2014 (n=32)

Country TotalYes BG,EE,GR,HU,IE,IT,PT,UK-WL 8No BE,HR,CY,CZ,FI,HU,FR,DE,DK,IS,LV,LI,LU,MT,NO,PL,RO,SK,SI,ES,SE,

UK-NI,UK-SC,UK-ENG24

Comment if promotional materials usedBG Adapted, in Bulgarian. 1EE ECDC influenza communication tools translated into Estonian. 1GR Poster, leaflet, banners. 1IE At time of preparation of campaign ECDC materials reviewed and used

as needed.1

IT Influenza toolkit has been translated in Italian. 1PT - 1UK-WL In formulating national guidance and policy. 1

NL,LT – not applicable.

The indicative time (according to your plan) for the start and duration of informationcampaign on seasonal influenza vaccination is provided in table 47. The median for durationof information campaign was 13 weeks.

Table 47. Indicative time for the beginning and duration of information campaign onseasonal influenza vaccination in 2012-13 influenza season in EU/EEA countries. Nationalseasonal influenza vaccination survey, March 2014 (n=28)

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Country Start week End week DurationBE 38 40 2BG 40 41 1HR 40 51 12CY 36 40 4DK 40 52 12EE 37 20 35FI 44 3 11FRa 40 04 16DE 36 52 16GR 36 52 16HU 44 6 15IS 34 13 20IE 40 20 32IT 40 50 10LV 40 43 4LI 40 48 8LU b - - -MT 1 4 4NO 38 4 19PL 35 45 10PT 39 52 -RO 38 52 15SK 41 45 5SI 40 9 22ES 38 52 14SE 42 - -UK-NI 39 15 28UK-SC 40 13 25UK-WL 40 52 12

88

aA specific campaign is performed to French overseas departments of the southern hemisphere during sincethe sixteenth week.b Campaign from 15 September until 15 October, re-launch in January.LT,NL,UK-ENG- Not applicable.CZ-No data.

Comments on promoting seasonal influenza vaccination:EE-Useful and positive (evaluation from health care providers) Scientist.IE-despite substantial promotion uptake is still disappointingly low.MT-There is still not enough public awareness of the benefits of influenza vaccination,particularly as many doctors still do not advise their patients to get vaccinated.PT-Duration is flexible depending on influenza season occurrence.ES- Time provided before is not accurate as it depends on. In 2012-2013 season startedbetween 17 September and 22 October 2012.UK-NI- Most of the time period is aimed at pregnant women who will get vaccinatedthroughout the season.

Section VI: USE OF ANTIVIRAL AGENTS FOR TREATMENT AND CHEMOPROPHYLAXIS OFINFLUENZAOf the 33 responding countries 21 and seven reported that Amantadine and Remantadinewas licensed in their country respectively. All countries reported that antiviral agents suchas Oseltamivir and Zanamivir (with exception of CY) was licensed for use (table 48).

Table 48. Licence for antiviral agents in 2012-13 influenza season in EU/EEA countries.National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalAmantadine

Licensed HR,CZ,FI,FR,DE,GRa,HU,IT,LV,LI,LT,LU,MT,NL,PL,RO,SK,ES,UK-NI,UK-WL,DK

21

Not licensed BE,BG,CY,EE,IS,IE,NO,PT,SI,SE,UK-ENG,UK-SC 12Remantadine

Licensed BG,FI,HU,LV,LT,PL, GRa 7Not licensed BE,HR,CY,CZ,DK,EE,FR,DE,IS,IE,IT,LI,LU,MT,NL,

NO,PT,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL26

OseltamivirLicensed BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,

LV,LI,LT,LU,MT,NL,NO,PL,PT,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL

33

Not licensed - 0Zanamivir

Licensed BE,BG,HR,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IE,IT,LV,LI,LT,LU,MT,NL,NO,PL,PT,RO,SK,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL

32

Not licensed CY 1a Licensed but not recommended for treatment or chemoprophylaxis because of the resistance of influenzaviruses to this agent.DK- no data for Amantadine.

89

Of 33 responding countries 23 reported ha that only neuraminidase inhibitors arerecommended for use in their countries; in eight countries both adamantanes andneuraminidase inhibitors are recommended (table 49).

The recommendations and/or guidelines (policy document) on antiviral use were availablein 24 countries (BG,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IE,LI,MT,NL,NO,PT,RO,SI,ES,SE,UK-ENG,UK-NI,UK-SC,UK-WL); in the remaining nine countries(BE,HR,IS,IT,LV,LT,LU,PL,SK) there were no such recommendations.

Table 49. Recommendation for antiviral agents use in 2012-13 influenza season in EU/EEAcountries. National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalAdamantanes are not recommendedagainst due to observed resistance

HU 1

Only neuraminidase inhibitors arerecommended

BE,CY,CZ,DK,EE,FR,DE,IS,IE,IT,NL,PT,SI,ES,UK-ENG,UK-SC,UK-WL,UK-NI, MT,BG,NO,LT,GR

23

Only some are recommended: no official,national recommendation

LU 1

Yes, they all are recommended HR,FI,LV,LI,PL,RO,SK,SE 8

Treatment

The population or medical risk groups, for which antiviral agents for treatment withsuspected or laboratory-confirmed influenza are recommended are presented in table 50.Antiviral agents are recommended for in-patients requiring treatment for severecomplicated ILI in all 24 countries; and for patients with progressive ILI in 22 countries.Antiviral agents also recommended for treatment of out-patients who are at higher risk ofinfluenza complications as a result of age and/or underlying medical conditions: children <5years of age in seven countries; for adults aged ≥65 years in 16 countries; for Individualsbelonging to risk groups in 18 countries; for pregnant women in 13 countries; and forresidents of nursing homes and other chronic-care facilities in 16 countries.

Table 50. Recommendations for treatment with suspected or laboratory-confirmedinfluenza in 2012-13 influenza season in EU/EEA countries. National seasonal influenzavaccination survey, March 2014 (n=24)

Population group/medical riskgroup

Recommended Norecommendation

For in-patients who have:- severe, complicated

influenza-like illness (ILI)BG,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IE,LI,MT,NLa,NO,PT,RO,SI,ES,SE,UK-ENG,UK-SC,UK-WL, UK-NI

- progressive influenza-likeillness

BG,CY,CZ,DK,EE,FI,,DE,GR,HU,IE,LI,MT,NLa,NO,PT,SI,ES,SE,UK-ENG, UK-SC,

FR, RO

90

UK-WL, UK-NI- who require hospitalisation

due to influenza- like illnessBG,DK,EE,FI,FR,DE,GR,IE,LI,NLa,NO,PT,SI,ES,SE,UK-ENG,UK-SC,UK-WL,UK-NI

CY,CZ,HU,MT,RO

For out-patients who are at higher risk of influenza complications on the basis of theirage or underlying medical conditions:

- Children < 2 years FI,GR,IE,PT,UK-SC,UK-WL,UK-NI

BG,CY,CZ,DK,EE,FR,DE,HU,LI,MT,NL,NO,RO,SI,SE,UK-ENG,ES

- Children < 5 years BG,FI,GR,PT,UK-SC,UK-WL,UK-NI

CY,CZ,DK,EE,FR,DE,HU,IE,LI,MT,NL,NO,RO,SI,SE,UK-ENG,ES

- Adults aged ≥65 years BG,CY,DK,EE,FI,FR,DE,GR,IE,NO,PT,SE,UK-ENG,UK-NI,UK-SC,UK-WL

CZ,HU,LI,MT,NL,RO,SI,ES

- Individuals belonging to riskgroups with e.g.: b

BG,CY,DK,EE,FI,FR,DE,GR,IE,LI,NLa,NO,PT,SE,UK-ENG,UK-NI,UK-SC,UK-WL

CZ,HU,MT,RO,SI,ES

For women who are pregnant orpostpartum (within 6 weeks afterdelivery)

DK,FI,FR,DE,GR,IE,NO,PT,SE,UK-ENG,UK-SC,UK-WL, UK-NI

BG,CY,CZ,EE,HU,LI,MT,NL,RO,SI, ES

For residents of nursing homes andother chronic-care facilities

BG,CY,EE,FI,FR,GR,IE,NL c,NO,PT,SI,ES,UK-ENG,UK-NI,UK-SC,UK-WL

CZ,DK,DE,HU,LI,MT,RO,SE

a Only individuals who belong to the following risk groups were recommended for treatment:- Patients with severe abnormalities or disorders of the heart or lung function, who despite medication have a

high risk of decompensation of heart or lung function.- Patients with serious liver or kidney failure.- Patients with a deficient immune system, for example because of an HIV infection, chemotherapy or

treatment with immunosuppressive medicine.b chronic pulmonary (including asthma), cardiovascular (except hypertension alone), renal, hepatic,haematological (including sickle cell disease), metabolic disorders (including diabetes mellitus), or neurologicand neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and musclesuch as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation],moderate to severe developmental delay, muscular dystrophy, or spinal cord injury), immunosuppressed,including those caused by medications or by HIV infection, <19 years who receive long-term aspirin therapy,morbid obesity (i.e., BMI ≥40);c For those residents it is recommended that they will only receive treatment when there is virologicalconfirmation of an outbreak. This means that in 48 hours two patients in one care unit are confirmed with aninfluenza virus infection.BE,HR,IS,IT,LV,LT,LU,SK,PL – Not applicable.

91

Other recommendations:IE- children with any condition that can compromise respiratory dysfunction, and children with moderate tosevere neurodevelopmental disorders such as cerebral palsy and intellectual disability.UK-SC- In primary care contractually the guidance should only be used once the SG issues notice that influenzais circulating and that antiviral agents can be used, except for outbreak situations.UK-WL- Antiviral agents are only licensed and recommended for the above groups when there is evidence thatinfluenza is circulating.FR- A curative treatment is recommended for an asymptomatic person at a very high risk of complicatedinfluenza if he/she has had a close contact with a laboratory confirmed or a probable case.

Post exposure prophylaxis

The population or medical risk groups, for which antiviral agents are recommended for post-exposure prophylaxis, are presented in table 51. For family or other close contacts of aperson who are at higher risk for influenza complications, and have not been vaccinatedwith influenza vaccine at the time of exposure, antiviral agents are recommended in sevencountries; for unvaccinated HCWs with occupational exposure and who did not use PPEb atthe time of exposure antiviral agents are recommended in six countries.

Table 51. Recommendations for post-exposure prophylaxis in 2012-13 influenza season inEU/EEA countries. National seasonal influenza vaccination survey, March 2014 (n=24)

Population group/ medical risk group Recommended Norecommendation

For family or other close contacts of a person whoare at higher risk for influenza complications andhave not been vaccinated with influenza vaccine atthe time of exposure

CY,IE,FR,UK-NI,UK-SC,UK-WL,GR

BG,CZ,DK,EE,DE,,HU,LI,MT,NL a,NO,PT,RO,SI,SE,UK-ENG,ES

For unvaccinated HCWs with occupationalexposure and who did not use PPEb at the time ofexposure

IE,LI,UK-NI,UK-SC,UK-WL,GR

BG,CY,CZ,DK,EE,FR,DE,HU,MT,NL,NO,PT,RO,SI,ES,SE,UK-ENG

a Only family contacts form a non-vaccinated environment might be considered for post-exposure prophylaxis,but not the general population.bPersonal protective equipment.FI- no data.BE,HR,IS,IT,LV,LT,LU,SK,PL – No applicable.

Other recommendations:IE- Decision for chemoprophylaxis is based on individual risk assessment of exposed person's risk for influenzacomplications, type and duration of contact and clinical judgement.SE- Unvaccinated in clinical risk groups. Immunocompromised irrespective of vaccination. Pregnant womenwith clinical risk factor in any trimester. Pregnant women without risk factors in 2 & 3 trimester.UK-WL -Recommended: Unvaccinated, risk-group individuals exposed (within 36/48 hours), when influenza iscirculating.FR- individuals in long term care facilities/care if there is a cluster of laboratory confirmed influenza.

Pre-exposure prophylaxis (PrEP)

The population groups or medical risk groups, whom antiviral agents are recommended forpre-exposure prophylaxis is presented in table 52. For individuals who are at high risk (e.g.

92

severely immunosupressed patients) for influenza-related complications who cannototherwise be protected during times when a high risk for exposure exists antiviral agents arerecommended in four countries.

Table 52. Recommendations for pre-exposure prophylaxis in 2012-13 influenza season inEU/EEA countries. National seasonal influenza vaccination survey, March 2014 (n=24)

Population group/ medical risk group Recommended Norecommendation

For individuals who are at high risk (e.g. severelyimmunosupressed patients) for influenza-relatedcomplications who cannot otherwise be protectedduring times when a high risk for exposure exists

IE,UK-SC,UK-WL, UK-NI

BG,CY,CZ,DK,EE,FR,DE,GR,HU,LI,MT,NO,PT,RO,SI,ES,SE,UK-ENG

FI- no data.BE,HR,IS,IT,LV,LT,LU,SK,PL – Not applicable.

Other recommendations:IE-Particularly in residential care facilities or settings where high risk patients.LI- Unvaccinated, directly exposed health care workers.SE- Only as an exception under very special circumstances, e.g. during local outbreak. Severelyimmunosuppressed are recommended NOT to receive PreEP.

Control of influenza outbreaks

The population groups or medical risk groups, whom antiviral agents are recommended forpre-exposure prophylaxis in case of an outbreak is presented in table 53. For individuals inlong term care facilities/care for immunocompromised if not vaccinated or if circulatinginfluenza strain is not matching the vaccine strains antiviral agents are recommended innine of 22 countries. For unvaccinated health care staff member who provide care topersons at high risk of complications in long term care facilities/ care forimmunocompromised patients if not vaccinated, or if circulating influenza strain is notmatching the vaccine strains, antiviral agents are recommended in seven of 22 countries.For all health care staff regardless of whether they received influenza vaccination ifcirculating influenza strain is not matching the vaccine strains antiviral agents arerecommended in two of 22 countries.

Table 53. Recommendations for pre-exposure prophylaxis in case of outbreak in 2012-13influenza season in EU/EEA countries. National seasonal influenza vaccination survey, March2014 (n=22)

Population group Recommended No recommendationFor individuals in long term carefacilities/care for immunocompromised ifnot vaccinated or if circulating influenzastrain is not matching the vaccine strains

CY, GR,IE,MT,NLa,SI,ES,UK-SC,UK-WL

BG,CZ,DK,EE,DE,FR,HU,NO,PT,RO,SE,UK-ENG,UK-NI

For unvaccinated health care staff whoprovide care to persons at high risk ofcomplications in long term care facilities/care for immunocompromised patients if

CY,GR,IE,MT,NLb,ES,UK-SC

BG,CZ,DK,EE,FR,DE,HU,NO,PT,RO,SI,SE,UK-ENG,UK-NI,

93

not vaccinated or if circulating influenzastrain is not matching the vaccine strains

UK-WL

For all health care staff regardless ofwhether they received influenzavaccination if circulating influenza strain isnot matching the vaccine strains

IE,UK-SC BG,CY,CZ,DK,EE,FR,DE,HU,MT,NL,NO,PT,RO,SI,ES,SE,UK-ENG,UK-NI,UK-WL, GR

Prisoners UK-SC BG,CY,CZ,DK,EE,FR,DE,HU,IE,MT,NL,NO,PT,RO,SI,ES,SE,UK-ENG,UK-NI,UK-WL, GR

Educational institutions UK-SC BG,CY,CZ,DK,EE,FR,DE,HU,IE,MT,NL,NO,PT,RO,SI,ES,SE,UK-ENG,UK-NI,UK-WL, GR

aAll not ill individuals who are living in a care unit with an influenza outbreak (this means that in 48 hours twopatients in one care unit are confirmed with an influenza virus infection) are recommended to receive pre-exposure prophylaxis, despite their immune or vaccination status and circulating influenza virus strains.b All not ill healthcare staff who are working in the coming next two weeks on the affected care unit with aninfluenza outbreak (this means that in 48 hours two patients in one care unit are confirmed with an influenzavirus infection) are recommended to receive pre-exposure prophylaxis, despite their immune or vaccinationstatus and circulating influenza virus strains.FI- no data.BE,HR,IS,IT,LV,LI,LT,LU,SK,PL – No applicable.

Comments:PT- outbreaks in institutions.SI- influenza outbreak in nursing homes.UK-SC -only in outbreak settings.

Of 33 responding countries 20 reported having antiviral resistance surveillance system inplace that monitors influenza antiviral resistance. The details if antiviral resistance areidentified in the laboratory and to whom antiviral resistance results should be notified arepresented, by country, in tables 54 and 54a.

Table 54. Antiviral resistance surveillance system in 2012-13 influenza season in EU/EEAcountries. National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalThere is no antiviralresistancesurveillance system inplace

BG,CY,CZ,EE,IS,LV,LI,LT,LU,MT,SK,SI,UK-NI 13

There is antiviralresistancesurveillance system inplace

BE,HR,DK,FI,FR,DE,GR,HU,IE,IT,NL,NO,PL,PT,RO,ES,SE,UK-ENG,UK-SC,UK-WL

20

Institution which should be notified if antiviral resistance is identified (n=20)

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Public health; BE,HR,FI,FR,DE,IT,NL,NO,PT,RO,SE,UK-ENG,UK-SC,UK-WL

14

Other DKa 1Public health;National regulatoryAgency;Others: ECDC/WHO

HU, GR 2

Public health;Others: To the treatingclinician, the referringlaboratory (if relevant)and the HealthProtection SurveillanceCentre (Nationalinfectious diseasesurveillance institute)

IEb 1

Others: National DrugInstitute

PL 1

Public health;Others: Clinician thatasked for the test is thefirst to be notified

ES 1

a Option other not specified.b Antiviral resistance testing is not done routinely on all samples. Antiviral resistance testing is undertaken on asmall proportion of clinical samples usually based on clinical requests.

Table 54a. Notification to clinicians if antiviral resistance is identified. National seasonalinfluenza vaccination survey, March 2014 (n=19)

Country TotalNot notified BE, IT,NL,PT,HU 5It is notified HR,DK,FR,DE,GR,IE,NO,PL,RO,ES,SE,UK-ENG,UK-SC,UK-WL 14

The way how notification is madeHR Professional publications 1DK By phone 1FR Personal contact 1DE Weekly reports of the influenza working group 1GR Email, personal communication 1IE To the treating clinician by the NVRL (phone or lab report) 1NO When clinically relevant finding of antiviral resistance is reported

back through the normal diagnostic system outcome reporting 1PL Information in medical documents 1RO Laboratory data form 1ES Electronic system 1SE Information to treating physician (single patient). Broad

communication in case of increased prevalence of resistant strains. 1UK-ENG By PHE 1

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UK-SC Laboratory report 1UK-WL Through Public Health Wales 1

BG,CY,CZ,EE,IS,LV,LI,LT,LU,MT,SK,SI,UK-NI - Not applicable.FI-no data.

Information on how antiviral agents are purchased for the individual patient is presented for33 responding countries in table 55. Twenty three countries reported that antiviral agentscan be purchased only if prescribed by a doctor.

Table 55. Purchase of antiviral agents in 2012-13 influenza season in EU/EEA countries.National seasonal influenza vaccination survey, March 2014 (n=33)

Country TotalPurchased only ifprescribed by doctor

BE,BG,HR,CY,CZ,DK,EE,FI,FR,DE,GR,HU,IS,IT,LI,LT,LU,MT,NL,NO,PL,PT,SK,SI,SE,UK-ENG,UK-NI,UK-SC,UK-WL

29

No need forprescription andavailable inpharmacies

- 0

Other: IE,LV,RO,ES 4IE By prescription for individuals but in outbreak situations

public health can make additional supplies available tofacility

1

LV Both depending on agent 1RO only in infectious diseases hospitals 1ES purchased only if prescribed by doctor, and Hospitals

provide antiviral for treatment (stockpiles in hospitals)1

Section VII: Technical support from ECDC and overall comments

Additional comments on the technical support from ECDC and other general commentswere provided by four countries. CY- On assessing the vaccine coverage and in general onguidelines on influenza management. No significant problems- I think our campaign must bemore intense.MT- More scientific-based evidence on added value to give vaccine to the elderly.PL-Methods which help to increasing coverage, acceptance of flu vaccine.PT-Effectiveness of influenza vaccine; how long does immunity last in healthy people? Needfor revaccination in subsequent years when vaccine does not change.

LimitationsThere are some limitations to this survey (many of which have been previously highlightedin VENICE publications). The limitations are summarised below:

Comparison of vaccination coverage data is difficult across European countries asdifferent methods of estimating coverage are often used; within a given country,

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comparisons between years may be difficult if methods or response rate differ byyear.

How countries enumerate the denominator data (numbers eligible for vaccination) isoften difficult to determine, especially when it comes to less specific groups, such asthe clinical risk groups and HCWs.

The enumeration of numbers vaccinated (numerator data) also has limitations ascountries may use either data provided from administrative records or immunisationregistries or from others surveys, both of which may have their own limitations.While the surveys report exact details on how numerator and denominator data arecalculated, the surveys do not explore or report the specific limitations.

Denominator data for clinical risk groups are particularly difficult to estimateaccurately for most EU/EEA countries, reflecting the lack of information systems(disease registers) or other standardised methodologies for collecting these data inthe countries.

Some countries have used population surveys to estimate the number of individualsat risk. But even this may not be comparable between countries as a variety ofmethodologies have been used (e.g. household surveys, mail, face to face, telephoneinterviews). The reasons for low or high uptake across EU/EEA countries were notcollected in these surveys: future studies are needed.

This particular survey (2012-2013 season) had some additional complexity due toexpansion in the number of questions and other changes in the format and structureof the questionnaire. Due to increased size of the questionnaire separate standalone sections need to be created on the web-based platform and linkages betweenrelated data across sections had to be created; this created additional difficulties fordata management and analysis. Discordant responses for some questions (e.g.questions relating to ability to monitor vaccination coverage and responses providedon vaccination coverage) were not always accurate and needed further clarificationwith the member states – some of which were not clarified at the time of this finalreport and will require further follow up.

Summary

1. Official policy for seasonal influenza vaccination in 2012-13 influenza season:

All 33 survey responding countries have an official national seasonal influenzavaccination policy/recommendations available in their countries; seven of themadopted or updated the previously developed national action plan to improvevaccination coverage for seasonal influenza as requested by European Commission(8); 15 countries did not have such plan in place at the time of the survey, however,respective policy to achieve higher vaccination coverage was in place in thesecountries at the time of the survey; two countries indicated that such plans are

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under development in their countries at the time of the survey; no plan was adoptedin nine countries.

2. Seasonal influenza vaccine was recommended in 2012-13 influenza season:

Of 33 responding countries 25 countries had influenza vaccine recommendations forthose aged 65 years and older. DE,GR, IS and NL recommended vaccination forthose aged 60 years and older, MT and PL recommended vaccination for those aged55 years and older, IE for those aged 50 years and older; in SK vaccine wasrecommended for those aged 59 years and older. Seven countries recommendedvaccine for children: two of them (EE,PL) for children of all ages; LV and SI forchildren aged >6months- 2years; FI >6months -3 years; MT >6months-5years; andSK for children aged >6 months – 12 years;

Of 33 responding countries 32 recommended influenza vaccine for HCWs; twenty-five of them had recommendations to vaccinate all HCWs; seven recommendedvaccination for only some (e.g. outpatient/inpatient/long term care) HCWs.Approximately one-third of MSs recommended vaccination for those working inessential (n=7) and military (n=11)and veterinary (n=7)services, or for peopleworking in the poultry (n=11) or swine (n=7) industry;

In all 33 counties people with chronic pulmonary, cardiovascular and renal diseaseswere recommended influenza vaccine; vaccine was recommended for those withhaematological disorders in 30 countries; metabolic disorders andimmunosupresssion due to disease or treatment in 32 countries; in 30 countriesvaccine was recommended for individuals suffering from hepatic; 17 countriesrecommended vaccine for those with long-term aspirin use (children <18 years old).In twenty eight countries individuals with HIV/AIDS were also recommended vaccine.Fifteen countries had recommendations to vaccinate those with morbid obesity;

Of 33 responding countries 30 recommended vaccination of pregnant women. In 28of these countriesvaccination of all pregnant women was recommended; in twocountries only those pregnant women with additional clinical risk wererecommended vaccine. Twenty-two of 30 countries recommended influenzavaccination for pregnant women in any trimester of pregnancy.

3. Vaccination coverage measured by administrative or estimated by survey methods in2012-13:

Was known in 26 countries for older populations (those aged ≥55, ≥60 and ≥65)and ranges from 1.0% in EE to 77.4% in UK-SC between countries; median was45%;

The coverage among health care workers was known in 13 countries, rangingfrom 9.5% in PL to 45.6% in UK-ENG; median was 28%;

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The coverage for clinical risk groups was known in nine countries ranging from28% in PT to 80.2% in UK-NI; median was 50%;

The coverage for pregnant women was known in ten countries: ranging from0.2% in LT to 64.6% of all pregnant women in UK- NI; median was 16%;

The coverage for residents of long-term care stay facilities was available in threecountries: 71.1% in SK, 73% in IE and 89% in PT.

4. Promoting vaccination Of 33 countries 22 countries have used specific information materials to

promote influenza vaccination coverage for the general public. Specificinformation for other population groups targeted for vaccine e.g. pregnantwomen or individuals with chronic medical conditions, existed in 19 and 24countries respectively. Most countries also had information materials forthose ≥65 years of age.

Of 33 countries specific information materials for health professionalsregarding seasonal influenza vaccination (e.g. leaflets, posters) existed in 21countries; professional medical societies and website were the most commonsource of information (in 11 and 12 countries respectively).

5. Use of antiviral agents for treatment and chemoprophylaxis of influenza Of 33 responding countries 20 reported having influenza antiviral resistance

surveillance systems in place to monitor antiviral resistance; Of 33 countries a policy document on use of antiviral agents existed in 24

countries; Antiviral agents for treatment were recommended for in-patients of severe

or complicated ILI in all 24 countries. Most countries also haverecommendations to use antiviral agents for treatment of out-patients athigher risk of influenza complications;

For control of influenza outbreaks, in nine of 22 countries antiviral agents arerecommended for individuals in long term care facilities/care ifimmunocompromised and not vaccinated, or the circulating influenza straindoes not match the vaccine strains. In seven of 22 countries antiviral agentsare recommended for unvaccinated health care staff member providing careto persons at high risk of complications in long term care facilities/ care forimmunocompromised patients if not vaccinated, or, if circulating influenzastrain does not match the vaccine strains. Antiviral agents are recommendedin two of 22 countries For all health care staff, regardless of whether theyreceived influenza vaccination, if circulating influenza strain does not matchthe vaccine strains.

6. Monitoring of vaccination coverage (discordant responses are highlighted in bracketsin red) Overall of 33 responding countries 27 monitor seasonal influenza vaccination

coverage using administrative method only; four countries use a combination of

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administrative and survey methods, and the remaining two use only surveymethodology to monitor influenza vaccination coverage;

Of 33 countries that have recommendations to vaccinate older populationgroups 22 reported that they monitor vaccination coverage for this specificpopulation group (26 provided VC);

Of 33 countries that recommend vaccine for those with clinical risk, 14 monitorvaccination coverage among them (9 provided VC);

Of 33 countries five reported that they monitor vaccination coverage amongpregnant women (10 provided VC);

Of 27 countries that recommend vaccine to HCWs seven monitor vaccinationcoverage among them (13 provided VC);

Of 29 countries which recommend vaccine for residents of long stay carefacilities, five monitor vaccination coverage (3 provided VC).

Conclusions

1. Official policy and recommendations for seasonal influenza vaccination in 2012-13influenza season:

The results of the survey demonstrate that although not all countries have a‘formal’ national action plan that has been endorsed to improve vaccinationcoverage for seasonal influenza (as recommended by European Commission )for the most part, most countries have policies that complying with EUrecommendations;

There were no significant changes in terms of age groups recommendedinfluenza vaccine either for healthy children/adolescents or older populationgroups when compared to the previous influenza season;

Recommendations for seasonal influenza vaccination exist in most countriesfor the older population, pregnant women, those with a clinical riskcondition, those living in long-term care facilities and health care workers;and additional six countries (21 in 2011-12 vs. 27 2012-13; CZ,FR,LV,LU,LI,HR)have recommended vaccination of those with hepatic diseases in comparisonto previous influenza season, and additional five countries (FI,HR,EE,IS,CY)have recommended vaccination for those with morbid obesity (10 in 2011-12vs. 15 in 2012-13); four additional countries (23 in 2011-12 vs.27 in 2012-13)recommended vaccine for pregnant women in 2012-13 in comparison to2011-12; three additional countries recommended vaccination of HCWs incomparison to previous influenza season (26 in 2011-12 vs.29 in 2012-13);

There is no consensus to vaccinate children across EU/EEA countries as onlyseven countries have a recommendation to vaccinate (different) age groupsunder <18 years of age; vaccination of other occupational groups (not HCWs)is not common across EU/EEA countries, as only one third or less of themrecommend influenza vaccine for these population groups.

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2. Vaccination coverage in 2012-13 influenza season:

Vaccination coverage varies widely across groups targeted by vaccinationacross EU/EEA countries;

Although all surveyed countries recommend vaccination of the olderpopulation groups, and vaccination coverage was reported by 26 countriesfor this group, uptake is low in many countries and does not meet the EUtarget. The vaccination coverage target of 75% in the older population groupswas achieved by the NL, UK-NI,UK-SC and almost achieved by UK-ENG andUK-WL; vaccination coverage was higher in RO and lower in PL,DE and IT in2012-13 than in the previous influenza season. Seven countries were not ableto provide vaccination coverage data for older population groups;

Although seasonal influenza vaccine is recommended for the main clinical riskgroups (e.g. pulmonary, cardiovascular, renal diseases, metabolic disordersand immunosupresssion due to disease or treatment) in all countries,vaccination coverage for persons with clinical risk was available forapproximately one-third of the countries (n=9). Vaccination coverage in thisgroup was considerably lower in comparison to the vaccination coverageamong the older population groups in most countries that provided thesedata and do not meet EU target for 2014-15, except the NL and UK-NI, whereuptake is high;

Vaccination coverage among HCWs was available from approximately half(n=13) of the 32 countries that recommend vaccine for this population group.In comparison to previous the influenza season three more countries wereable to provide vaccination coverage data for the 2012-13 season (LT,GR,HR).Coverage varied greatly between countries with a few countries reportingmoderate (RO,UK-ENG) uptake. In the remaining countries vaccinationcoverage was low and lower for HCWs than for other targeted populationgroups. Vaccination coverage data among staff of long-stay care facilities wasavailable in two (IE, PT) countries and was as low as among other HCWs;

Among residents of long-stay care facilities, vaccination coverage was veryhigh in those countries that were able to provide data for this specificpopulation group; however uptake was known in only three countries;

Although vaccination was recommended for pregnant women in 30 of thesurveyed countries, vaccination coverage in this group was reported by justten of these countries; in comparison to previous season an additional threecountries were able to report uptake for this specific population group(IE,IT,LT). Vaccination coverage was moderate in UK-SC,UK-NI,UK-ENG andUK,WL; in the remaining countries vaccination coverage was low;

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The results of this survey have shown that achieving high vaccinationcoverage for those who are at risk of developing severe complications due toinfluenza infection remains a serious public health challenge.

Recommendations

Countries that do not have seasonal influenza vaccination action plan toachieve higher seasonal influenza vaccination coverage are encouraged todevelop and adopt such a document.

In order to enable assessment of the performance of the national influenzavaccination programme, countries should strive to develop and strengtheninfluenza vaccination coverage monitoring systems for target groups forwhom vaccination is most commonly recommended (older populations,those with clinical risk, pregnant women and HCWs). Those countries that donot monitor vaccination coverage among older population groups shouldstrive to implement uptake monitoring systems. Data on uptake should becollected on an annual basis at the end of each influenza season.

This survey shows that vaccination coverage rates need to be improvedamong all targeted groups: the older population (except in countries thathave already achieved vaccination target of 75%), those with clinical risk,pregnant women and health care workers.

Countries are advised to: encourage health care workers to proactivelyrecommend seasonal influenza vaccination to persons identified as key targetgroups by the national vaccination programme (including themselves andtheir peers); to implement communication campaigns on influenza andinfluenza vaccines specifically for these population groups; to supportvaccination by providing adequate funding.

Judging by the results of this survey, more work is needed to explore howrecommendations (at both national and international levels) can beeffectively translated into higher vaccination coverage. This may also requireresearch to identify the reasons for non-vaccination in countries with lowvaccination coverage rates and possible drivers for vaccination in countriesthat have already achieved targets of 75%.

To enable comparison of vaccination coverage rates at European level,annual population-based surveys conducted using the same or similarmethodologies may be useful.

Surveys on seasonal influenza vaccination policies and coverage should beconducted annually. Surveys conducted at the same time of each year willallow better planning of the work for VENICE project and also gatekeepers ineach country. It is also proposed to shorten surveys in order to get improvedata quality. The standardised information provided by such surveys enables

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ongoing monitoring of progress onwards implementation of internationallyaccepted recommendations and goals relating to seasonal influenzavaccination at EU level.

References

(1) de Blasio BF, Xue Y, Iversen B, Gran JM. Estimating influenza-related sick leave inNorway: was work absenteeism higher during the 2009 A(H1N1) pandemiccompared to seasonal epidemics? Euro Surveill. 2012;17(33):pii=20246.

(2) Molinari NA, Ortega-Sanchez IR, Messonnier ML, Thompson WW, Wortley PM,Weintraub E, et al. The annual impact of seasonal influenza in the US: measuringdisease burden and costs. Vaccine. 2007;25(27):5086-96.

(3) Schanzer DL, McGeer A, Morris K. Statistical estimates of respiratory admissionsattributable to seasonal and pandemic influenza for Canada. Influenza Other RespiViruses. 2013 Sep;7(5):799-808.

(4) Nicoll A, Ciancio BC, Lopez Chavarrias V, Mølbak K, Pebody R, Pedzinski B, et al.Influenza-related deaths--available methods for estimating numbers and detectingpatterns for seasonal and pandemic influenza in Europe. Euro Surveill.2012;17(18):pii=20162.

(5) Centers for Disease Control and Prevention (CDC). Influenza. Epidemiology andprevention of vaccine preventable diseases. The pink book: course textbook. 12thed. Second printing. Atlanta, GA: CDC; May 2012. Available from:http://www.cdc.gov/vaccines/pubs/pinkbook/flu.html

(6) Nicoll A, Sprenger M. Low effectiveness undermines promotion of seasonal influenzavaccine. Lancet Infect Dis. 2013;13(1):7-9.

(7) Poehling KA, Szilagyi PG, Staat MA, Snively BM, Payne DC, Bridges CB, et al. Impact ofmaternal immunization on influenza hospitalizations in infants. Am J Obstet Gynecol.2011;204(6 Suppl 1):S141-8.

(8) Commission of the European Communities. Proposal for a Council recommendationon seasonal influenza vaccination. Brussels; Commission of the EuropeanCommunities; 2009. Available from:http://ec.europa.eu/health/ph_threats/com/Influenza/docs/seasonflu_rec2009_en.pdf

(9) Nicoll A, Ciancio B, Tsolova S, Blank P, Yilmaz C. The scientific basis for offeringseasonal influenza immunisation to risk groups in Europe. Euro Surveill.2008;13(43):pii=19018.

(10) World Health Organization (WHO). Prevention and control of influenza pandemicsand annual epidemics. Resolution of the Fifty-Sixth World Health Assembly

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WHA56.19. Tenth plenary meeting, 28 May 2003. Geneva: WHO. [Accessed 4-Jan-2013]. Available from:http://apps.who.int/gb/archive/pdf_files/WHA56/ea56r19.pdf

(11) Influenza vaccines. Wkly Epidemiol Rec. 2005;80(33):279-87.

(12) Vaccine European New Integrated Collaboration Effort (VENICE). National seasonalinfluenza vaccination survey in Europe, 2007/2008 influenza season. Collaborationbetween VENICE project and ECDC. VENICE II. July - October 2009. [Accessed 1 Apr2012]. Available from:http://venice.cineca.org/Final_2009_Seasonal_Influenza_Vaccination_Survey_in_Europe_1.0.pdf

Annex 1. Questionnaire

National seasonal influenza vaccination surveyfor 2012-13 influenza season in EU/EEA,

October 2013- January 2014ECDC_HPSC Version 12 January 2014 (24/01/2014)

Dear Colleagues,

We kindly ask you, to fill in the seasonal influenza vaccination survey questionnaire withyour country-specific data for the INFLUENZA SEASON 2012-13. The questionnaire containseight sections, all must be completed but you can do one at a time (for your convenience):

Section I: Groups recommended for seasonal influenza vaccinationSection II: Vaccination coverage dataSection III: Methods for monitoring vaccination coverage, safety and effectivenessSection IV: Vaccine procurement and deliverySection V: Promoting seasonal influenza vaccinationSection VI: Use of antiviral agents for treatment and chemoprophylaxis of influenzaSection VII: Technical support from ECDC and overall comments

If you have any questions, please contact Jolita Mereckiene by email:[email protected]

COUNTRY:

GATEKEEPER:__________________ __________________________________

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NAME OF PERSON WHO FILLS QUESTIONNAIRE (IF DIFFERENT FROM ABOVE):________________________

TITLE/FUNCTION: ____________

CONTACT EMAIL:____________________________________________________

CONTACT PHONE NUMBER: __________________

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Section I: GROUPS RECOMMENDED SEASONAL INFLUENZA VACCINATION (2012-13influenza season) BY NATIONAL/REGIONAL AUTHORITY

Q1. Are there national seasonal influenza vaccination recommendations (e.g. age andtarget group recommendations and guidelines) available in your country?

Yes No

Q2. If no, which authority in your country issues recommendations for seasonal influenzavaccination?

Regional authorities Communal (local) authorities Professional groups only No authority OtherPlease specify other __________

Q3. Did your country adopt a National Action Plan to improve vaccination coverage forseasonal influenza vaccination as recommended by EC 22/12/2009?http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:348:0071:0072:EN:PDF

Yes, plan was adopted Yes, plan was developed previously and updated according EC recommendation Plan is under development No need to adopt as vaccination coverage meet EC/WHOtargets Plan not adopted

If national Action plan is available on website, please specify link to the publisheddocument:

If national Action plan is not available on website, please copy it here:

Overall population

Q4. Is the policy document (guidelines and recommendations) recommending seasonalinfluenza vaccine to ALL > 6 months of age?

Yes No

Healthy children or adolescents

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Q5. For which of the following healthy children or adolescents was seasonal influenzavaccine recommended?

NO recommendation for healthy children or adolescents of any age Recommended for all children> 6 months – 12 months of age Recommended for all children between 13 months- 24 months of age Recommended for all children between 25 months- 36 months of age Recommended for all children between 37 months- 49 months of age Recommended for all children between 50 months- 60 months of age Recommended for all children and adolescents between 1 - 18 years of age Recommended for all children and adolescents> 6 months – 12 years of age Recommended for some children and adolescents> 6 months - 18 years of age Recommended for all children and adolescents> 24 months -18 years of age OtherPlease specify ________

Q6. For the 2012-13 season did your country introduce any changes in relation to seasonalinfluenza vaccination recommendations for healthy children and adolescents incomparison to recommendations for influenza season 2011-12?

Yes, Please specify ________No

Q7. If vaccine was recommended for healthy children and adolescents please specify howthe vaccination programme was funded (This question opens only if answer is“recommended for …. “:* Out of pocket means not reimbursed, paid by vaccinee.

Vaccine was paid by: (drop down menu – with more than one option)- National insurance scheme/- National health service/- Regional health service/- Private insurance/- Out of pocket*/- Parent/guardian employer/- Other (please specify) ________- No data available

If different for regions, please specify__________

Co-payment for vaccine:Yes, Please specify ________No

Administration of vaccine (vaccination) was paid by (drop down menu – with more thanone option)

- National insurance scheme/- National health service/

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- Regional health service/- Private insurance/- Out of pocket*/- Parent/guardian employer- Other (please specify) ________- No data available

If different for regions, please specify_______

Co-payment for administration of vaccine (vaccination)Yes, Please specify ________No

If in your country there are any issues with reimbursement of cost of vaccine, or itsadministration, that may influence vaccination coverage, please specify (e.g. delay inreimbursement for vaccinee)__________________________

Adults

Q8. For which of the following adult age groups was seasonal influenza vaccinerecommended?

NO recommendation for healthy adults of any age Recommended for healthy adults 19-50 years old Recommended for healthy adults 51– 55 years old Recommended for healthy adults56 - 60 years old Recommended for healthy adults 61- 64 years old Recommended for healthy adults >18 years old

Recommended for ALL adults>50 years old Recommended for ALL adults>55 years old Recommended for ALL adults>59 years old Recommended for ALL adults>60 years old Recommended for ALL adults>65 years old Other, Please specify __________________

If other, specify age group__________________

Q9. Has your country introduced any changes in relation to seasonal influenza vaccinationrecommendations for adults in comparison to recommendations for influenza season2011-12?


Q10. If vaccine was recommended for healthy adults please specify how the vaccinationprogramme was funded (This question opens only if answer is “recommended for …. “):* Out of pocket means not reimbursed, paid by vaccinee.

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Vaccine was paid by: (drop down menu – with more than one option)- National insurance scheme/- National health service/- Regional health service/- Private insurance/- Out of pocket*/- Employer/- Other (please specify) ________- No data available




- National insurance scheme/- National health service/- Regional health service/- Private insurance/- Out of pocket*/- Employer- Other (please specify) ________- No data available



If in your country there are any issues with reimbursement of cost of vaccine or itsadministration that may influence vaccination coverage, please specify (e.g. delay inreimbursement for vaccinee)__________________________

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Clinical risk groups

Q11. For which of the following clinical risk groups (individuals with chronic diseases orunderlying clinical condition) was seasonal influenza immunisation recommended (tick asappropriate)* “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.**Recommended defined here and in the following questions that there is specific written recommendation inthe official policy document that this population group have to receive seasonal influenza vaccine

Medical condition/risk Norecommenda

tion*

Recommended**

Comments

Chronic pulmonary (such as chronicobstructive pulmonary disease, cysticfibrosis, asthma) diseaseCardiovascular (such as congenital heartdisease, congestive heart failure andcoronary artery disease, excepthypertension) diseaseRenal diseaseHepatic diseaseHematological disorders (such as sicle celldisease)Metabolic disorders (such as inheritedmetabolic disorders and mitochondrialdisorders, including diabetes mellitus)Immunosuppression due to disease ortreatment (including asplenia/ splenicdysfunction, organ transplantation,cancer, but other than HIV/AIDS)HIV/AIDSChronic neurologic diseases orneuromuscular conditions ( e.g. includingdisorders of the brain, spinal cord,peripheral nerve, and muscle such ascerebral palsy, epilepsy (seizuredisorders), stroke, intellectual disability(mental retardation), moderate to severedevelopmental delay, musculardystrophy, or spinal cord injury).Long-term aspirin use (in children up to 18years old)Any condition that can compromiserespiratory functionMorbid obesity (Body Mass Index (BMI)>40)

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Other (Please specify)

Q12. Has your country introduced any changes in relation to seasonal influenzavaccination recommendations for children, adolescents and adults with clinical conditionsin comparison to recommendations for influenza season 2011-12?


Q13. If vaccine was recommended for clinical risk groups please specify how thevaccination programme was funded (This question opens only if answer is “recommendedfor …. “):* Out of pocket means not reimbursed, paid by vaccinee.


If different for regions, please specify__________Co-payment for vaccine:






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Pregnancy related vaccination

* “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.**Recommended defined here and in the following questions that there is specific written recommendation inthe official policy document that this population group have to receive seasonal influenza vaccine

Q14. Is seasonal influenza vaccination recommended for pregnant women?NO recommendation Recommended only for those with medical/clinical risk indication Recommended for all

Q15. Please indicate in which trimester of pregnancy seasonal influenza vaccination isrecommended? (This question opens only if answer is “recommended for….”)

Any trimester 2nd trimester 3rd trimester

Comments:

Q16. Is seasonal influenza vaccination recommended to women in the postpartum*period (giving birth during influenza season) if not vaccinated during pregnancy?* “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.**Recommended defined here and in the following questions that there is specific written recommendation inthe official policy document that this population group have to receive seasonal influenza vaccine

NO recommendation Recommended only forthose with medical/clinical risk indication Recommended for all

* Within 6 weeks after delivery. If other recommendation, please specify_______

Q17. If seasonal influenza vaccination is recommended to women in pregnancy or in thepostpartum* period (giving birth during influenza season), please provide informationwhere such vaccination is performed. (This question opens only if answer is “recommendedfor….”)

Maternity out-patient clinic Well-baby clinic General practitioners/Family doctors Antenatal clinicAt the time of delivery (hospital, home or other clinic setting)

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Post-natal clinic Other,

Please specify ________

Q18. Has your country introduced any changes in relation to seasonal influenzavaccination recommendations for pregnant and post partum women in comparison torecommendations for influenza season 2011-12?


Q19. If vaccine was recommended for pregnant women please specify how thevaccination programme was funded: (This question opens only if answer is “recommendedfor….)* Out of pocket means not reimbursed, paid by vaccinee.







Co-payment for administration of vaccine (vaccination)Yes, Please specify ________

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NoIf in your country there are any issues with reimbursement of cost of vaccine or itsadministration that may influence vaccination coverage, please specify (e.g. delay inreimbursement for vaccinee)__________________________

Health care workers

Q20. Is seasonal influenza vaccination recommended for health care workers?

*”Voluntary” defined here as individual free will (choice) when deciding on seasonal influenza vaccination andthere is no penalty for not getting the vaccine.** “Mandatory” (compulsory, obligatory, authoritatively ordered) defined here as vaccination for which thereis a “penalty” for those who refuse seasonal influenza vaccination.

NO recommendation to HCWs Recommended to some HCWs (e.g. outpatient/inpatient/long term care)(Please specify _____) Recommended to all HCWs If Yes, wasvaccination: Voluntary*/ Mandatory**

If answer “Yes”Please specify what the “penalty” in your country is____Is there an exemption policy based on philosophical or religious background for

HCWs in your country? YesNoIf yes, please specify________

Comments:

Q21. Has your country introduced any changes in relation to seasonal influenzavaccination recommendations for health care workers in comparison to recommendationsfor influenza season 2011-12?


Q22. If vaccine was recommended for health care workers please specify how thevaccination programme was funded: (This question opens only if answer is “recommendedfor….)* Out of pocket means not reimbursed, paid by vaccinee.Vaccine was paid by: (drop down menu – with more than one option)

- National insurance scheme/- National health service/- Regional health service/- Private insurance/- Out of pocket*/- Employer/

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- Other (please specify) ________- No data available



Administration of vaccine (vaccination)was paid by (drop down menu – with more thanone option)






Q23. Is seasonal influenza vaccination recommended for other occupational groups? (tickas appropriate)* “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.**Recommended defined here and in the following questions that there is specific written recommendation inthe official policy document that this population group have to receive seasonal influenza vaccineProfession No

recommendation

Recommended Comments

Police & FiremenMilitaryBorder/Immigration control/ customs

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VeterinaryPublic transport (e.g. ground, rail, air, marine)(if specific recommendations for particulartransport workers, please specify)Educational staff - e.g. primary/secondaryschools, preschool centres, kindergartens,crèches - please specify if for all or for someeducational staff.)Community services (energy, electricity,water)Postal servicePoultry industry workersSwine industry workersFamilies raising swine, poultry or geeseSocial care workersLaboratory workers working in notmedical/public health laboratories (e.g.laboratory workers who work with avianinfluenza viruses in the environmental/academic sector )Wildlife environmentalists (workers who workwith birds directly e.g. bird ringing)Other (Please specify)

Q24. Has your country introduced any changes in relation to seasonal influenzavaccination recommendations for occupational settings in comparison torecommendations for influenza season 2011-12?


Q25. If vaccine was recommended for other occupational groups please specify how thevaccination programme was funded: (This question opens only if answer is “recommendedfor….)* Out of pocket means not reimbursed, paid by vaccinee.



Co-payment for vaccine:

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Administration of vaccine (vaccination)was paid by (drop down menu – with more thanone option)





Population groups in closed communities

Q26. Is seasonal influenza vaccination recommended for specific populationsliving/working/staying in closed communities? (tick as appropriate)* “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.**Recommended defined here and in the following questions that there is specific written recommendation inthe official policy document that this population group have to receive seasonal influenza vaccinePopulation group No

recommendationRecommended Comments

PrisonersChildren in day care centres, boardingschools etc.Residents of long term care facilitiesOther, Please specify

Q27. Has your country introduced any changes in relation to seasonal influenzavaccination recommendations for populations living/working/staying in closedcommunities in comparison to recommendations for influenza season 2011-12?


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Q28. If vaccine was recommended for populations living/working/staying in closedcommunities please specify how the vaccination programme was funded: (This questionopens only if answer is “recommended for….)* Out of pocket means not reimbursed, paid by vaccinee.









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Household contacts or care takers

Q29. Is seasonal influenza vaccination recommended for household contacts or caretakers of the following population groups?* “No recommendation” defined here and in the following questions that there is no specific writtenrecommendation in the official policy document on whether this population group should be vaccinated ornot.**Recommended defined here and in the following questions that there is specific written recommendation inthe official policy document that this population group have to receive seasonal influenza vaccineHousehold contact/Carer of: No


Infants <6 months of ageImmunosuppressed individualsPersons with clinical risk indicationAdults (>65)Other, Please specify

Q30. Has your country introduced any changes in relation to seasonal influenzavaccination recommendations for household contact/carer in comparison torecommendations for influenza season 2011-12?


Q31. If vaccine was recommended for household contacts or care takers please specifyhow the vaccination programme was funded: (This question opens only if answer is“recommended for….)* Out of pocket means not reimbursed, paid by vaccinee.

Vaccinewas paid by: (drop down menu – with more than one option)- National insurance scheme/- National health service/- Regional health service/- Private insurance/- Out of pocket*/- Employer/- Other (please specify) ________- No data available




- National insurance scheme/- National health service/

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- Regional health service/- Private insurance/- Out of pocket*/- Employer- Other (please specify) ________- No data available




Q32. Is seasonal influenza vaccination recommendedfor travellers? Yes No

If yes, is this recommendation restricted to certain regions/countries Yes, this is restricted to some regions/countries

Please specify______________ Recommended but not specified

Q33. When elaborating /updating recommendation policy in your country for seasonalinfluenza vaccination, have you used the following published ECDC/WHO documents:- Council recommendation on seasonal influenza vaccination 22/12/2009 http://eur-

lex.europa.eu/LexUriServ/LexUriServ.do?uri=OJ:L:2009:348:0071:0072:EN:PDF Yes No

- ECDC GUIDANCE Priority risk groups for influenza vaccination, 2008(http://www.ecdc.europa.eu/en/publications/Publications/0808_GUI_Priority_Risk_Groups_for_Influenza_Vaccination.pdf)

Yes No

- ECDC scientific advice on seasonal influenza vaccination of children and pregnantwomen 2012(http://www.ecdc.europa.eu/en/publications/publications/seasonal%20influenza%20vaccination%20of%20children%20and%20pregnant%20women.pdf)

Yes No

- European Medicine Agency (Summary of product characteristics): e.g.http://www.ema.europa.eu/docs/en_GB/document_library/EPAR_-_Product_Information/human/001101/WC500103709.pdf

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Yes No

- Vaccines against influenza WHO position paper – November 2012http://www.who.int/wer/2012/wer8747.pdf

Yes No

- Others, please specify__________

Q34. Overall comments on groups recommended for seasonal influenza vaccination andneeds for further scientific guidance from ECDC

Section II: VACCINATION COVERAGE DATA (SEASON 2012-13)

Q35. If available, please provide data on vaccination coverage for the entire population

Entire population

Vaccination coverage wasNOT measured for the entire population Vaccination coverage was measured by:

Administrative method, please provide coverage___________%Survey method, please provide coverage___________%Combination of administrative and survey method, please provide

coverage___________%Immunisation registry, please provide coverage___________%

If vaccination coverage was measured by other method/s please specifymethod_________ and provide vaccination coverage___________%

Q36. Have you observed any change in vaccination coverage for the entire populationcompared to previous season (2011-12)?

- Yes, please specify and list 3 main reasons for the change.- No

Comments for reasons for change in vaccination coverage:

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Vaccination coverage by age groups

Children and adolescents

Q37. If available, please provide data on vaccination coverage for children (>6 months –18 years of age)

Total No data available for this age group Vaccination coverage was measured by:



of which healthy children (this appears if there is an answer on vaccination

coverage)

No data available Vaccination coverage was measured by:



Children with clinical condition/risk (this appears if there is an answeron vaccination coverage)





Q38. If available, please provide data on vaccination coverage for children (>6 – 12months of age)

Total No data available for this age group

122

Vaccination coverage was measured by:Administrative method, please provide coverage___________%Survey method, please provide coverage___________%Combination of administrative and survey method, please provide


of which healthy children (this appears if there is an answer on vaccination

coverage)









Q39. If available, please provide data on vaccination coverage for children andadolescents (1 – 18 years of age)




of which

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healthy children (this appears if there is an answer on vaccinationcoverage)









Q40. If available, please provide data on vaccination coverage for children andadolescents (>6months – 18 years of age by groups)

Age group Vaccination coverage inseason

2012-13

Comment Nodata

12 months - 36 months of age37 months - 60 months of age5 years - 18 yearsIf additional age groups, pleasespecify______________

Comments concerning vaccination coverage in children and adolescence:

AdultsQ41. If available, please provide data on vaccination coverage for adults (age groups >18years of age)

Total No data available for this age group Vaccination coveragewas measured by:

Administrative method, please provide coverage___________%

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Survey method, please provide coverage___________%Combination of administrative and survey method, please provide


of which healthy adults (age group >18) (this appears if there is an answer on

vaccination coverage)




adults (any age group >18) with clinical condition/risk (this appears ifthere is an answer on vaccination coverage)





Q42. If available, please provide data on vaccination coverage for adults (age groups >50years of age)




of which healthy adults (>50 years of age) (this appears if there is an answer on


125




adults (>50 years of age) with clinical condition/risk (this appears ifthere is an answer on vaccination coverage)

No data available Vaccinationcoverage was measured by:




Q43. If available, please provide data on vaccination coverage for adults (age group >55years of age)






No data available Vaccination coveragewas measured by:

Administrative method, please provide coverage___________%Survey method, please provide coverage___________%Combination of administrative and survey method, please providecoverage___________%Immunisation registry, please provide coverage___________%


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If vaccination coverage was measured by other method/splease specifymethod_________ and provide vaccination coverage___________%

Q44. If available, please provide data on vaccination coverage for adults (age groups >60years of age)

Total No data available for this age group Vaccination coverage wasmeasured by:




vaccination coverage) No data available Vaccination coverage was measured by:







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Q45. If available, please provide data on vaccination coverage for adults (age groups > 65years of age)





vaccination coverage) No data available Vaccination coverage was measured by:



No dataavailable Vaccination coverage was measured by:




Children, adolescents and adults with clinical risk

Q46. If available, please provide data on vaccination coverage for those with clinical risk(Age group >6 months-64 years)

Total No data available for this population group Vaccination coverage was measured by:

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If vaccination coverage was measuredby other method/s please specifymethod_________ and provide vaccination coverage___________%

Q46a. If available, please provide data on vaccination coverage for those with clinical risk(Other age group with clinical risk than >6 months-64 years, please specify age)

Total No data availableOther age group with clinical risk, please specify age ______________ Vaccination coverage was measured by:



Comments concerning vaccination coverage in adults:

Vaccination coverage for other population groupsPregnant women

Q47. If available, please provide data on vaccination coverage for pregnant womenTotal




of which Healthy (this appears if there is an answer on vaccination coverage)


Administrative method, please provide coverage___________%

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Survey method, please provide coverage___________%Combination of administrative and survey method, please provide


With clinical condition/risk (this appears if there is an answer onvaccination coverage)




Health care workers

Definition (in a footnote)- Medical and other staff, including those in primary care, secondary and long term facilities,

who have regular, clinical contact with patients. This includes staff such as doctors, dentists,nurses, psychologists, paramedical professionals such as occupational therapists,physiotherapists, diagnostic radiographers (incl. radiologists), ambulance workers, porters,and students;

- Laboratory and other health staff (including mortuary staff) who have direct contact withpotentially infectious clinical specimens. This includes those in academic (or commercialresearch) laboratories who handle clinical specimens;

- Non-clinical ancillary staff, who may have social contact with patients, but not usually of aprolonged or close nature. This group includes receptionists, ward clerks, maintenance staffsuch as engineers, gardeners, cleaners, and other administrative staff working in hospitalsand primary care settings, etc.

Reference (adapted): The UK Association of National Health Occupational Physicians (ANHOPS) guidance on Immunisation of healthcareworkers defines three categories of healthcare workershttp://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733758763

Q48. If available, please provide data on vaccination coverage for health care workersTotal




of which

130

o In outpatient health care setting (e.g. GP, family medicine practice, polyclinic/outpatient centres (this appears if there is an answer on vaccination coverage)



o In inpatient health care setting (e.g. hospitals) (this appears if there is an answeron vaccination coverage)




o In long term health care setting (e.g. nursing homes) (this appears if there is ananswer on vaccination coverage)

No dataavailable Vaccination coverage was measured by:




Other occupational groups essential for functional public sector (including police, military,public transport, community supply etc)

Q49. If seasonal influenza vaccine is recommended to other occupational groups andthese data are available, please provide data on vaccination coverage for otheroccupational groups essential for functional public sector

Total No data available Vaccination coverage was measured by:

Administrative method, please provide coverage___________%Survey method, please provide coverage___________%

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Combination of administrative and survey method, please providecoverage___________%Immunisation registry, please provide coverage___________%

of which Police (this appears if there is an answer on vaccination coverage)



Military/Armed forces (including air/marine, etc.) (this appears if thereis an answer on vaccination coverage)



Public transport (including air, ground, water) (this appears if there isan answer on vaccination coverage)

No data available Vaccination coverage wasmeasured by:


Community supply (water/electricity, energy) workers (this appears ifthere is an answer on vaccination coverage)



Other (this appears if there is an answer on vaccination coverage) No data available

132

Please indicate group___________________________ Vaccination coverage was measured by:



Population groups living in closed communities

Q50. If available, please provide data on vaccination coverage for residents of long termcare facilities



If vaccination coverage was measuredby other method/s please specifymethod_________ and provide vaccination coverage___________%

Q51. If available, please provide data on vaccination coverage for prisoners No data available Vaccination coverage was measured by:



Comments concerning vaccination coverage in specific population groups living in closedcommunities:

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Q52. Overall comments on obtained vaccination coverage in your country

Section III: METHODS TO MONITOR VACCINATION COVERAGE, SAFETY ANDEFFECTIVENESS

Q53. Which method has been used to measure vaccination coverage for season 2012-13? Administrative method only Survey method only

Please specify the frequency: annual/biannual/other, specify_____ Combination of administrative and survey methods

Q54. Have there been changes in the methods for monitoring influenza vaccinationcoverage in comparison to those used in the influenza season 2011-12?

Yes, Please specify________ No

Q55. Please specify current methods used for monitoring vaccination coverage ofpopulation groups recommended for vaccination (tick the corresponding practice in yourcountry)

Population groups Nomonitoring

Administrative method Survey Norecommendatio

nManual Electronic Manual Electronic

Entire populationChildren andadolescentsAdults: aged 18 - <65 years oldAdults: aged >65years oldIndividuals withmedical/riskconditions (clinicalrisk groups)Pregnant womenHealth care workersEssential publicsector workersPrisonersResidents of longterm careinstitutions

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EducationalinstitutionsHouseholdcontact/Carer of:Infants <6 months ofageImmunosuppressedindividualsPersons with clinicalrisk indicationAdults (>65)Other, please specify

Q56. If administrative methods are used to measure the numerator assessing influenzavaccination coverage, please provide some more information below (you can tick morethan one)

Population groups Medical records Immunisation registry*No Yes No Yes

Non-electronic(paper form)

Electronic Manual Electronic

Entire populationChildren andadolescentsAdults aged 18 - < 65years oldAdults aged >65 yearsoldIndividuals withmedical/riskconditions (clinicalrisk groups)Pregnant womenHealth care workersEssential public sectorworkersPrisonersResidents of longterm care institutionsEducationalinstitutionsHouseholdcontact/Carer of:Infants <6 months ofageImmunosuppressedindividualsPersons with clinicalrisk indicationAdults (>65)

135

Other, please specify*If electronic immunisation registry is under development when is it expected to be available for use todocument exposure to influenza vaccines: ________ (year)

Comments:

Q57. Please provide estimate on how many vaccination sites report vaccination coverage- less than 50% of all sites- between 50 and 70% of all sites- more than 70% of all sites- more than 90% of all sites- unknown/has not been assessed and not possible to estimate

Q58. Please provide estimate on time lag between vaccination and reporting to a medicalrecord or immunization registry

No time lag, enteredat the time of vaccine administration1 week2 weeks3 weeks1 month > 1 month, please specify _______

Q59. If regional/national electronic immunization registry exists, can you link data with:Medical records in General practitioner (Family doctor) clinics

YesNo

Medical records in hospitalsYesNo

Influenza laboratory dataYesNo

Comments:

Numerator and denominator assessment

Q60. If surveys are used to measure influenza vaccination coverage, please provide somemore information below (you can tick more than one)

SurveyNo Yes

Type of Surveydrop down menu

householdindividual

Survey modedrop down

menuin person

by telephoneby mail

Sampling strategy Sample size

Responserate(%)

Comments

Non ProbabilityDrop down menu:

Probabilitysampling Drop

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QuotasConvenienceOther, pleasespecify…

down menu:Simple randomSystematicStratified(assessment, LQAS_ Lot QualityAssessmentSampling *)MultistageCluster (EPI)Other, specify____

Q61.If survey was conducted, please specify if vaccination coverage was estimated for thefollowing population groups? drop down menu

Entire populationChildren and adolescents

Please specify age group_______________Adults aged 18 - < 65 years oldAdults aged >65 years old

Older adult age group (e.g. >60 years old)Please specify age group_______________

Individuals with medical/risk conditions (clinical risk groups)Individuals with medical/risk conditions aged >6months-64 yearsIndividuals with medical/risk conditions- other age group

Please specify age group_______________Pregnant womenHealth care workersEssential workers in the public sectorPrisonersResidents of long term care institutionsEducational staffOther, please specify________

Q62. If pharmaceutical data are used to measure the numerator in assessing influenzavaccination coverage, please provide some more information below (you can tick morethan one)

Population groups Vaccine distribution data from industryNo Yes

Month/year CommentsEntire population

Population groups Vaccine distribution data from national purchaserNo Yes

Date/year CommentsEntire population

Population groups Vaccine data by sales and distribution from pharmaciesNo Yes

Date/Yes CommentsEntire population

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Children and adolescentsAdultsIndividuals with medical/risk conditions(clinical risk groups)Pregnant womenHealth care workers

If OTHER pharmaceutical data are used to measure the numerator, pleasespecify________________

Q63. Please specify if any of the following vaccine data collection methods are used inyour country

Aggregate collection of number of vaccines administered Aggregate collection of number of vaccines distributed (industry) Aggregate collection of number of vaccines distributed (national purchaser) Aggregate collection of number of vaccines sales (private pharmacies) Payment/ reimbursement claims OtherIf other, specify: ____________

Q64. What is the most frequent interval at which numerator data assessing influenzavaccination coverage is collected?

Weekly Monthly Every two months Every three months (quarterly) Once, at the end of flu season Annually, specific date/time of year _______________________________ Other, specify: ________________________________________________ Different intervals for different groups whom vaccine is recommended,specify_________

Q65. Please provide information on what type of assessment is used in your country fordenominator

Population groups Denominator assessmentNo Yes

Type Please specify (e.g. populationregistries, Central statistic data,

diseases registries and etc.)Entire populationChildren and adolescentsAdultsIndividuals with medical/riskconditions (clinical risk groups)Pregnant womenHealth care workersEssential public sector workersPrisonersResidents of long term careinstitutionsEducational institutions

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Other, please specify

Q66. Do you perform scientific studies on vaccination coverage?NoYes,

If YES please specify the method(s) you use

_________________

do you have Geographical Information Systems (GIS) tools availablefor study purposes?

Yes, please specify

what is the time frame and frequency of the used method(s)______________________

what is the target group for the vaccination coverage study/ies______________________

Comments:

139

Q67a. Is there a system available to monitor influenza vaccine safety (adverse eventsfollowing immunization) in vaccinated individuals and what data should be reported tothe national level?

Yes, case based data including age, sex and suspected symptomsshould bereported Yes, case based data with a personal identifier and suspected symptoms

should be reported Yes, aggregated data including age, sex and suspected symptomsshould be reported No, there is no such system

Other relevantinformation, please specify__________

If yes, can these data be linked to an immunisation registry if available? Yes No Other relevant information, please specify__________

Q67b. Is there a system available to monitor influenza vaccine safety (adverse eventsfollowing immunization) in vaccinated individuals and what data should be reported tothe regional level?

Yes, case based data including age, sex and suspected symptoms should bereported Yes, case based data with a personal identifier and suspected symptoms should bereported Yes, aggregated data including age, sex and suspected symptoms should bereported No, there is no such system Other relevant information, please specify__________

If yes, can these data be linked to an immunisation registry if available? Yes No Other relevant information, please specify__________

Q68. Is there a system available to monitor influenza vaccine breakthrough* infections invaccinated individuals and what data should be reported?

*a breakthrough infection is defined as laboratory-confirmed influenza infection >14 days afterseasonal influenza vaccination in the current season (i.e. vaccine failure)

Yes, case based data should be reported to the national level Yes, aggregated should be reported to the national level Yes, case based data should be reported to the regional level Yes, aggregated should be reported to the regional level No, there is no such system Other, specify__________

If yes, can these data be linked an the immunisation registry if available? Yes No Other, specify__________

140

Q69. Is it mandatory to report adverse events following vaccination?Yes

If yes, to whom

NoQ70. Do you perform studies on influenza vaccine safety?

YesIf yes, please provide more details for studies performed within the last 5

yearsStudy/year Methods

usedTarget group (byage/occupation/healthstatus)

Link topublication

please specify at what time intervals (every year, every other year)? do you perform product-specific safety studies?

No

Q71. Do you perform studies on influenza vaccine effectiveness?Yes

If yes, please provide more details for studies performed within the last 5

yearsStudy/year Methods

usedTarget group (byage/occupation/healthstatus)

Link topublication

please specify at what time intervals (every year, every other year)? do you perform product-specific effectiveness studies?

No

Q72. Overall comments on monitoring methods

141

Section IV: VACCINE PROCUREMENT AND DELIVERY

Q73. For vaccination season 2012-13, please provide information on number of doses:

Doses: Number No data CommentPurchased*DistributedUsedEstimated number of doses*If parallel systems exist (public/private), please provide if possible an estimate for overallnumber of doses purchased in your country

Q74. Was the amount of vaccines purchased in your country sufficient to covervaccination for recommended population groups?

YesNo, please specifyNo data available

Q75. Where there vaccine shortages and/or stock-outs in your country during the lastinfluenza season that affected vaccination coverage?

Yes, Please specify ______NoNo data available

Q76. Please indicate the vaccine products used in your country in 2012-13: (you can tickmore than one) and for which population group it has been usedType of vaccine Product name(s) and

manufacturer on themarket

Used for:Please specify(age group/groupwith medicalcondition/s)

Comments

Trivalent inactivatedintramuscularinfluenza vaccineTrivalent liveattenuated nasalvaccineTrivalent inactivatedintra dermal vaccineProduced bymanufacturerOther, please specify

Q77. Please indicate if you have used ECDC information site on influenza vaccines:http://ecdc.europa.eu/en/healthtopics/seasonal_influenza/vaccines/Pages/influenza_vaccination.aspx?

142

YesNo

Q78. Please select where influenza vaccines are administeredGeneral Practitioners (Family doctors) surgeries Hospitals WorkplacesSchools Pharmacies Supermarkets Walk-in clinics Well-baby clinics Paediatricians Other, please specify_____

Q79. Please select the different health care workers that may administer vaccines: Doctors Nurses PharmacistsOthersIf other, specify__________________

Q80. If administered by health care staff except doctors are special protocols (e.g. licence,standing orders) needed to administer vaccine?

Yes No

Q81. Is there a financial incentive to the vaccine administrators to achieve highvaccination coverage?

Yes, please specify ______ No

Q82. Is there a mechanism to feedback achieved vaccination coverage targets torespective vaccinator/vaccinating clinic?

Yes, please specify _______ No

Q83. Overall comments on vaccine procurement and delivery

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Section V: PROMOTING SEASONAL INFLUENZA VACCINATION

Q84. Are information campaigns for seasonal influenza vaccination conducted in yourcountry that targets the general public and the following specific population groups?

General public Yes NoPopulation aged >65 Yes NoPregnant women Yes NoPersons with chronic medical conditions Yes NoOther groups, please specify:______ Yes No

Q85. Which of the following sources was used to inform the general public? (tick all thatapply)

RadioTVNews papers Leaflets Posters WebsiteOtherOther, specify______________

Q86. Who sponsors the media campaigns for public for seasonal influenza vaccinationprogramme? (tick all that apply)

National/regional health authorities Pharmaceutical sector Public service announcement*OtherOther, specify______________

* Advertisement content and production is provided by government, including nationalhealth

Comments:

Q87. Are information campaigns for seasonal influenza vaccination conducted in yourcountry that targets health care workers?

Yes No

If yes, which of the following did your country use (tick all that apply)RadioTVNews papers Leaflets Posters

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WebsitesE-based learning modules Professional medical societies National medical publicationsOther, please specify______________

Q88. Have you used ECDC promotional materials to support your information campaignson seasonal influenza vaccination?http://ecdc.europa.eu/en/healthtopics/seasonal_influenza/communication_toolkit/Pages/communication_toolkit.aspx

Yes,Please specify _____No

Q89. Please provide indicative time (according to your plan) for the start and duration ofyour information campaign on seasonal influenza vaccination?

- Start week no _____- End week no: _____- Duration in number of weeks: __

Q90. Overall comments on promoting seasonal influenza vaccination

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Section VI: USE OF ANTIVIRAL AGENTS FOR TREATMENT AND CHEMOPROPHYLAXIS OFINFLUENZA

Q91. Are the following antiviral agents licensed in your country?Adamantanes:

AmantadineRemantadine

Neuraminidase inhibitors:OseltamivirZanamivirOthers, please specify___________

Q92. Are they recommended for use in your country?Yes, they all are recommendedOnly some are recommended, please specify_____Only neuraminidase inhibitors are recommendedAdamantanes are not recommended due to observed resistance

Q93. Are there recommendations and/or guidelines (policy document) on antiviral use inyour country?

Yes No

Treatment

Q94. If recommendation exists, who is recommended treatment with suspected orlaboratory-confirmed influenza?

Population group/medical risk group Norecommendation

Recommended

Comments

For in-patients who have:- severe, complicated influenza-like illness- progressive influenza-like illness- who require hospitalisation due to

influenza- like illnessFor out-patients who are at higher risk of influenzacomplications on the basis of their age orunderlying medical conditions:

- Children < 2 years- Children < 5 years- Adults aged >65 years- Individuals belonging to risk groups with

e.g.:chronic pulmonary (including asthma),cardiovascular (except hypertension alone),renal, hepatic, hematological (includingsickle cell disease), metabolic disorders

146

(including diabetes mellitus), or neurologicand neurodevelopment conditions(including disorders of the brain, spinalcord, peripheral nerve, and muscle such ascerebral palsy, epilepsy [seizure disorders],stroke, intellectual disability [mentalretardation], moderate to severedevelopmental delay, muscular dystrophy,or spinal cord injury), immunosuppressed,including those caused by medications orby HIV infection, <19 years who receivelong-term aspirin therapy, morbid obesity(i.e., BMI ≥40);

For women who are pregnant or postpartum(within 6 weeks after delivery)For residents of nursing homes and other chronic-care facilitiesOther, specify___________

Post exposure prophylaxis

Q95. If recommendation exists, who is recommended post-exposure prophylaxis?

Population group/ medical risk group Norecommendation

Recommended

Comments

For family or other close contacts of a person whoare at higher risk for influenza complications andhave not been vaccinated with influenza vaccine atthe time of exposureFor unvaccinated HCWs with occupationalexposure and who did not use PPE* at the time ofexposureOther, specify_______*Personal protective equipment

Pre-exposure prophylaxis

Q96. If recommendation exists, who is recommended pre-exposure prophylaxis?

Population group/ medical risk group Norecommendation

Recommended

Comments

For individuals who are at high risk (e.g. severelyimmunosupressed patients) for influenza-relatedcomplications who cannot otherwise be protectedduring times when a high risk for exposure exists

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Other, specify_______

Control of influenza outbreaks

Q97. If recommendation exists, who is recommended pre-exposure prophylaxis in case ofan outbreak? (tick as appropriate)Population group No


For individuals in long term carefacilities/care forimmunocompromised if notvaccinated or if circulating influenzastrain is not matching the vaccine strainsFor unvaccinated health care staffmember who provide care to persons athigh risk of complications in long termcare facilities/ care forimmunocompromised patients if notvaccinated or if circulating influenzastrain is not matching the vaccine strainsFor all health care staff regardless ofwhether they received influenzavaccination if circulating influenzastrain is not matching the vaccine strainsPrisonersEducational institutionsOther, specify___________

Q98. Does your country have an antiviral resistance surveillance system in place thatmonitors influenza antiviral resistance?

Yes No

Q99. If antiviral resistance is identified in the laboratory to whom should it be notified inyour country? (tick as appropriate)

Public health National regulatoryAgency Others, specify___________

Q100. If antiviral resistance is identified in the laboratory are clinicians notified Yes, please specify how _______ No

Q101. How antiviral might be purchased on the individual level?Purchased only if prescribed by doctorNo need for prescription and available in pharmacies Other, specify_______

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Section VII: Technical support from ECDC and overall comments

Q102. In which areas related to influenza vaccination would you like to receive technicalsupport from ECDC?

Please specify: ___________________________________________

Q103. Overall comments on activities, reporting, achievements and obstacles encounteredduring influenza season 2012-13

Thank you very much for your time!

149

Annex 2. Glossary of terms used in questionnaire

Breakthrough infection is defined as laboratory-confirmed influenza infection >14 days afterseasonal influenza vaccination in the current season (i.e. vaccine failure).

Health Care Workers- Medical and other staff, including those in primary care, secondary and long

term facilities, who have regular, clinical contact with patients. This includesstaff such as doctors, dentists, nurses, psychologists, paramedicalprofessionals such as occupational therapists, physiotherapists, diagnosticradiographers (incl. radiologists), ambulance workers, porters, and students;

- Laboratory and other health staff (including mortuary staff) who have directcontact with potentially infectious clinical specimens. This includes those inacademic (or commercial research) laboratories who handle clinicalspecimens;

- Non-clinical ancillary staff, who may have social contact with patients, butnot usually of a prolonged or close nature. This group includes receptionists,ward clerks, maintenance staff such as engineers, gardeners, cleaners, andother administrative staff working in hospitals and primary care settings, etc.

Reference (adapted): The UK Association of National Health Occupational Physicians (ANHOPS) guidance onImmunisation of healthcare workers defines three categories of healthcare workershttp://www.hpa.org.uk/web/HPAweb&HPAwebStandard/HPAweb_C/1195733758763

Mandatory vaccination of health care workers (compulsory, obligatory, authoritativelyordered) defined as vaccination for which there is a “penalty” for those who refuse seasonalinfluenza vaccination.

No recommendation- defined here that there is no specific written recommendation in theofficial policy document on whether this population group should be vaccinated or not.

Out of pocket means not reimbursed, paid by vaccinee.

Recommended defined here that there is specific written recommendation in the officialpolicy document that this population group have to receive seasonal influenza vaccine.

Voluntary vaccination of health care workers defined here as individual free will (choice)when deciding on seasonal influenza vaccination and there is no penalty for not getting thevaccine.

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Annex 3. The draft template for country specific profile

Name of the country: XInfluenza immunisation policy/General factsNational seasonal influenza recommendations Yes/NoNational Action Plan (NAP) as requested by EC Adopted/updated/respective policy

in place/under development/notadopted

URL link to NAP If providedTotal population of the country EurostatThose ≥65 Eurostat

Vaccination recommendations (population groups targeted by vaccination) in 2012-13influenza seasonOverall population Yes/NoHealthy children and adolescents Yes/NoOlder population groups (≥50;≥55;≥59;≥60;≥65 yearsof age)

Yes/No

Clinical risk groups (by each clinical risk group) Yes/NoPregnancy related vaccination (including post-partumwomen)

Yes/No

Health Care Workers (including staff of long stay carefacilities)

Yes/No

Other occupational groups Yes/NoPopulation groups in closed communities Yes/NoHousehold contacts or care takers Yes/No

Payment mechanism for vaccine and its administration in 2012-13 influenza season for thefollowing population groupsHealthy children and adolescents National insurance scheme;

National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Older population groups (≥50;≥55;≥59;≥60;≥65 yearsof age)

National insurance scheme;National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Clinical risk groups (by each clinical risk group) National insurance scheme;National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Pregnancy related vaccination (including post-partumwomen)

National insurance scheme;National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Health Care Workers (including staff of long stay care National insurance scheme;

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facilities) National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Other occupational groups National insurance scheme;National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Population groups in closed communities National insurance scheme;National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Household contacts or care takers National insurance scheme;National health service; Regionalhealth service; Private insurance;Out of pocket; Employer

Vaccination coverage in from 2008-09 to 2012-13 influenza season (for countries thatprovided the following data for one to five influenza seasons) by method of datacollection (administrative and /or survey)

2008-09

2009-10

1010-11

2011-12

2012-13

Children/adolescents % % % % %Older population groups % % % % %Clinical risk groups % % % % %Pregnant women % % % % %HCWs % % % % %Staff in long stay care facilities % % % % %Residents in long stay care facilities % % % % %

Monitoring of vaccination coverage in 2012-13influenza seasonMethod used to monitor influenzavaccination coverage

Administrative method only; Surveymethod only; Combination ofadministrative and survey methods

Yes/No

Method used (administrative, survey) tomonitor vaccination coverage by populationgroup

Entire population; Children andadolescents; Adults: aged 18 - < 65years old; Adults: aged >65 yearsold; Individuals with medical/riskconditions (clinical risk groups);Pregnant women; Health careworkers; Essential public sectorworkers; Prisoners; Residents oflong term care institutions;Educational institutions; householdcontacts/carers

Yes/No

Details on administrative method used Entire population; Children and Yes/No

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(medical records vs. immunisation registry;manual vs. electronic) by population groups

adolescents; Adults: aged 18 - < 65years old; Adults: aged >65 yearsold; Individuals with medical/riskconditions (clinical risk groups);Pregnant women; Health careworkers; Essential public sectorworkers; Prisoners; Residents oflong term care institutions;Educational institutions; householdcontacts/carers

Details for survey method used Type of the survey; survey mode;sample size; population targeted

Yes/No

Numerator assessment Pharmaceutical data; administrativedata; frequency of numeratorassessment

Yes/No

Denominator assessment by populationgroups and data source

Entire population; Children andadolescents; Adults; Individuals withmedical/risk conditions (clinical riskgroups); Pregnant women; Healthcare workers; Essential public sectorworkers; Prisoners; Residents oflong term care institutions;Educational institutions

Yes/No

Scientific studies conducted for vaccinationcoverage; vaccine safety and vaccineeffectiveness

URL link to the studies if provided Yes/No

Vaccine safety monitoring (adverse eventsfollowing immunisation)

Data collected at thenational/regional level; data linkagewith immunisation registry;

Yes/No

Influenza vaccine procurement and delivery n 2012-13 influenza seasonNumber of doses purchased, distributed,used, estimated

No. of doses

Type of vaccine/Product name used Trivalent inactivated non adjuvanted vaccine(TIV);trivalent inactivated adjuvantedvaccine (aTIV);Trivalent live attenuated nasalvaccine (LAIV); Qudrivalent attenuated nasalvaccine (LAIV); Qudrivalent inactivated non-adjuvanted vaccine (QIV)

Promoting of seasonal influenza vaccination in 2012-13 influenza seasonCommunication with general public andavailability of information materials fortargeted population groups (those ≥65;pregnant women; those with clinical risk

Radio,TV,News papers, Leaflets,Posters, Website

Yes/No

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condition)Communisation with health professionals Radio, TV, News papers, Leaflets,

Posters, Website, Professionalmedical societies

Yes/No

Use of antiviral agents for treatment and chemoprophylaxis of influenza in 2012-13influenza seasonUse of antivirals for treatment for in-patientand out-patient who are at higher risk ofinfluenza complications

Yes/No

Use of antivirals for post-exposureprophylaxis

Yes/No

Use of antivirals for pre-exposureprophylaxis

Yes/No

Use of antivirals for control of influenzaoutbreaks

Yes/No

Existence of antiviral resistance surveillancesystem

Yes/No

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